Sleep and Breathing

, Volume 8, Issue 1, pp 15–29 | Cite as

Refractory Insomnia and Sleep-Disordered Breathing: A Pilot Study

  • Barry Krakow
  • Dominic Melendrez
  • Samuel A. Lee
  • Teddy D. Warner
  • Jimmy O. Clark
  • David Sklar
Original Article


Objective: To assess an uncontrolled, open-label trial of sleep-disordered breathing (SDB) treatment on two different samples of chronic insomnia patients. Method: In Study 1 (Retrospective), data from one diagnostic and one continuous positive airway pressure (CPAP) titration polysomnogram were compiled from 19 chronic insomnia patients with SDB. Objective polysomnogram indicators of sleep and arousal activity and self-reported sleep quality were measured. In Study 2 (Prospective), clinical outcomes were assessed after sequential cognitive-behavioral therapy (CBT) and SDB therapy (CPAP, oral appliances, or bilateral turbinectomy) were provided to 17 chronic insomnia patients with SDB. Repeat measures included the Insomnia Severity Index, Functional Outcomes of Sleep Questionnaire, Pittsburgh Sleep Quality Index, and self-reported insomnia indices and CPAP use. Results: In Study 1, seven objective measures of sleep and arousal demonstrated or approached significant improvement during one night of CPAP titration. Sixteen of 19 patients reported improvement in sleep quality. In Study 2, Insomnia Severity Index, Functional Outcomes of Sleep Questionnaire, and Pittsburgh Sleep Quality Index improved markedly with CBT followed by SDB treatment and achieved an average outcome equivalent to curative status. Improvements were large for each treatment phase; however, of 17 patients, only 8 attained a nonclinical level of insomnia after CBT compared with 15 patients after SDB therapy was added. Self-reported insomnia indices also improved markedly, and self-reported SDB therapy compliance was high. Conclusions: In one small sample of chronic insomnia patients with SDB, objective measures of insomnia, arousal, and sleep improved during one night of CPAP titration. In a second small sample, validated measures of insomnia, sleep quality, and sleep impairment demonstrated clinical cures or near-cures after combined CBT and SDB therapies. These pilot results suggest a potential value in researching the pathophysiological relationships between SDB and chronic insomnia, which may be particularly relevant to patients with refractory insomnia.


Insomnia sleep-disordered breathing sleep fragmentation obstructive sleep apnea upper airway resistance syndrome polysomnography continuous positive airway pressure oral appliance therapy 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Bonnet MH, Arand DL. Diagnosis and treatment of insomnia. Respir Care Clin N Am 1999;5:333–348Google Scholar
  2. 2.
    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed, text revisionWashington, DC American Psychiatric Association 2000 597661Google Scholar
  3. 3.
    Nofzinger EA, Buysse DJ, Reynolds CFIII, Kupfer DJ. Sleep disorders related to another mental disorder (nonsubstance/primary): a DSM-IV literature review. J Clin Psychiatry 1993;54:244–255Google Scholar
  4. 4.
    Nowell PD, Buysse DJ, Reynolds CFIII et al. Clinical factors contributing to the differential diagnosis of primary insomnia and insomnia related to mental disorders. Am J Psychiatry 1997;154:1412–1416Google Scholar
  5. 5.
    Buysse DJ, Reynolds CFIII, Hauri PJ et al. Diagnostic concordance for DSM-IV sleep disorders: a report from the APA/NIMH DSM-IV field trial. Am J Psychiatry 1994;151:1351–1360Google Scholar
  6. 6.
    Hatoum HT, Kong SX, Kania CM, Wong JM, Mendelson WB. Insomnia, health-related quality of life and healthcare resource consumption. A study of managed-care organization enrollees. Pharmacoeconomics 1998;14:629–637Google Scholar
  7. 7.
    Kim K, Uchiyama M, Liu X et al. Somatic and psychological complaints and their correlates with insomnia in the Japanese general population. Psychosom Med 2001;63:441–446Google Scholar
  8. 8.
    Leger D, Scheuermaier K, Philip P et al. SF-36: evaluation of quality of life in severe and mild insomniacs compared with good sleepers. Psychosom Med 2001;63:49–55Google Scholar
  9. 9.
    Katz DA, McHorney CA. The relationship between insomnia and health-related quality of life in patients with chronic illness. J Fam Pract 2002;51:229–235Google Scholar
  10. 10.
    Lamarche CH, Ogilvie RD. Electrophysiological changes during the sleep onset period of psychophysiological insomniacs, psychiatric insomniacs, and normal sleepers. Sleep 1997;20:724–733Google Scholar
  11. 11.
    Bonnet MH, Arand DL. Physiological activation in patients with sleep state misperception. Psychosom Med 1997;59:533–540Google Scholar
  12. 12.
    Merica H, Blois R, Gaillard JM. Spectral characteristics of sleep EEG in chronic insomnia. Eur J Neurosci 1998;10:1826–1834Google Scholar
  13. 13.
    Bonnet MH, Arand DL. Heart rate variability in insomniacs and matched normal sleepers. Psychosom Med 1998;60:610–615Google Scholar
  14. 14.
    Morin CM. The nature of insomnia and the need to refine our diagnostic criteria. Psychosom Med 2000;62:483–485Google Scholar
  15. 15.
    Rosa RR, Bonnet MH. Reported chronic insomnia is independent of poor sleep as measured by electroencephalography. Psychosom Med 2000;62:474–482Google Scholar
  16. 16.
    Hall M, Buysse DJ, Nowell PD et al. Symptoms of stress and depression as correlates of sleep in primary insomnia. Psychosom Med 2000;62:227–230Google Scholar
  17. 17.
    Richardson GS, Roth T. Future directions in the management of insomnia. J Clin Psychiatry 2001;62(suppl):39–45Google Scholar
  18. 18.
    Perlis ML, Smith MT, Andrews PJ, Orff H, Giles DE. Beta/gamma EEG activity in patients with primary and secondary insomnia and good sleeper controls. Sleep 2001;24:110–117Google Scholar
  19. 19.
    Perlis ML, Kehr EL, Smith MT et al. Temporal and stagewise distribution of high frequency EEG activity in patients with primary and secondary insomnia and in good sleeper controls. J Sleep Res 2001;10:93–104CrossRefGoogle Scholar
  20. 20.
    Vgontzas AN, Bixler EO, Wittman AM et al. Middle-aged men show higher sensitivity of sleep to the arousing effects of corticotropin-releasing hormone than young men: clinical implications. J Clin Endocrinol Metab 2001;86:1489–1495Google Scholar
  21. 21.
    Vgontzas AN, Bixler EO, Lin HM et al. Chronic insomnia is associated with nyctohemeral activation of the hypothalamic-pituitary-adrenal axis: clinical implications. J Clin Endocrinol Metab 2001;86:3787–3794Google Scholar
  22. 22.
    Shaver JL, Johnston SK, Lentz MJ, Landis CA. Stress exposure, psychological distress, and physiological stress activation in midlife women with insomnia. Psychosom Med 2002;64:793–802Google Scholar
  23. 23.
    Morin C. Insomnia: Psychological Assessment and ManagementNew York, NY Guilford Press 1993 915Google Scholar
  24. 24.
    Edinger JD, Wohlgemuth WK, Radtke RA, Marsh GR, Quillian RE. Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial. JAMA 2001;285:1856–1864Google Scholar
  25. 25.
    Thase ME. Antidepressant treatment of the depressed patient with insomnia [review]. J Clin Psychiatry 1999;60(suppl 17):28–31 discussion 46–48Google Scholar
  26. 26.
    Murtagh DR, Greenwood KM. Identifying effective psychological treatments for insomnia: a meta-analysis. J Consult Clin Psychol 1995;63:79–89Google Scholar
  27. 27.
    Chesson AL, Jr, Anderson W M, Littner M et al. Practice parameters for the nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep 1999;22:1128–1133Google Scholar
  28. 28.
    Morin CM, Hauri PJ, Espie CA et al. Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine review. Sleep 1999;22:1134–1156Google Scholar
  29. 29.
    Lichstein KL, Wilson NM, Johnson CT. Psychological treatment of secondary insomnia. Psychol Aging 2000;15:232–240Google Scholar
  30. 30.
    Lichstein KL, Riedel BW, Wilson NM, Lester KW, Aguillard RN. Relaxation and sleep compression for late-life insomnia: a placebo-controlled trial. J Consult Clin Psychol 2001;69:227–239Google Scholar
  31. 31.
    Espie CA, Inglis SJ, Harvey L. Predicting clinically significant response to cognitive behavior therapy for chronic insomnia in general medical practice: analysis of outcome data at 12 months posttreatment. J Consult Clin Psychol 2001;69:58–66Google Scholar
  32. 32.
    Harvey L, Inglis SJ, Espie CA. Insomniacs’ reported use of CBT components and relationship to long-term clinical outcome. Behav Res Ther 2002;40:75–83Google Scholar
  33. 33.
    American Academy of Sleep Medicine. The international classification of sleep disorders. Lawrence, Kansas Allen Press Inc. 1997, 52–58Google Scholar
  34. 34.
    Krakow B, Germain A, Tandberg D et al. Sleep breathing and sleep movement disorders masquerading as insomnia in sexual assault survivors with PTSD. Compr Psychiatry 2000;41:49–56Google Scholar
  35. 35.
    Krakow B, Artar A, Warner TD, et al. Sleep disorder, depression, and suicidality in female sexual assault survivors. Crisis 2000;21:163–170Google Scholar
  36. 36.
    Krakow B, Germain A, Warner TD, et al. The relationship of sleep quality and posttraumatic stress to potential sleep disorders in sexual assault survivors with nightmares, insomnia and PTSD. J Trauma Stress 2001;14:647–665Google Scholar
  37. 37.
    Krakow B, Melendrez D, Santana E, et al. Prevalence and timing of sleep disturbance in Cerro Grande Firestorm victims. Sleep 2001 24(suppl) A394Google Scholar
  38. 38.
    Krakow B, Hollifield M, Johnston L, et al. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial. JAMA 2001;286:537–545Google Scholar
  39. 39.
    Krakow B, Johnston L, Melendrez D, et al. An open-label trial of evidence-based cognitive behavioral therapy for nightmares and insomnia in crime victims with PTSD. Am J Psychiatry 2001;158:2043–2047Google Scholar
  40. 40.
    Krakow B, Melendrez DC, Johnston LG, et al. Sleep dynamic therapy for Cerro Grande Fire evacuees with posttraumatic stress symptoms: a preliminary report. J Clin Psychiatry 2002;63:673–684Google Scholar
  41. 41.
    Krakow B, Lowry C, Germain A, et al. A retrospective studyon improvements in nightmares and posttraumatic stress disorder following treatment for co-morbid sleep-disordered breathing. J Psychosom Res 2000;49:291–298Google Scholar
  42. 42.
    Melendrez D, Krakow B, Johnston L, Sisley B, Warner TD. A prospective study on the treatment of “complex insomnia”—insomnia plus sleep-disordered breathing—in a small series of crime victims with PTSD, Sleep 2001. 24(suppl) A120Google Scholar
  43. 43.
    Krakow B, Melendrez D, Johnston L, et al. Sleep-disordered breathing, psychiatric distress, and quality of life impairment in sexual assault survivors. J Nerv Ment Dis 2002;190:442–452Google Scholar
  44. 44.
    American Academy of Sleep Medicine. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force. Sleep 1999;22:667–689Google Scholar
  45. 45.
    Krakow B, Melendrez D, Ferreira E, et al. Prevalence of insomnia symptoms in sleep-disordered breathing patients. Chest 2001;120:1923–1929Google Scholar
  46. 46.
    Krakow B, Melendrez D, Warner TD, et al. To breathe, perchance to sleep: sleep-disordered breathing and chronic insomnia among trauma survivors. Sleep Breath 2002;6:189–202Google Scholar
  47. 47.
    Chung KF, Krakow B, Melendrez D, Warner TD, Sisley B. Relationships between insomnia and sleep-disordered breathing [letter] Chest, 2003. 123:310–313Google Scholar
  48. 48.
    Namen AM, Dunagan DP, Fleischer A, et al. Increased physician-reported sleep apnea: the National Ambulatory Medical Care Survey. Chest 2002;121:1741–1747Google Scholar
  49. 49.
    Ohayon MM, Roth T. What are the contributing factors for insomnia in the general population?. J Psychosom Res 2001;51:745–755Google Scholar
  50. 50.
    Guilleminault C. Clinical features and evaluation of obstructive sleep apnea. In: Kryger MH, Roth T, Dement WC, Principles and Practice of Sleep Medicine. 2nd ed. London, WB Saunders Co. 1994, 552–558Google Scholar
  51. 51.
    Krakow B, Melendrez D, Pedersen B, et al. Complex insomnia: insomnia and sleep-disordered breathing in a consecutive series of crime victims with nightmares and PTSD. Biol Psychiatry 2001;49:948–953Google Scholar
  52. 52.
    Hosselet JJ, Norman RG, Ayappa I. Detection of flow limitation with a nasal cannula/pressure transducer system. Am J Respir Crit Care Med 1998;157:1461–1467Google Scholar
  53. 53.
    Montserrat JM, Farre R, Ballester E, et al. Evaluation of nasal prongs for estimating nasal flow. Am J Respir Crit Care Med 1997;155:211–215Google Scholar
  54. 54.
    Guilleminault C, Stoohs R, Duncan S. Snoring (I). Daytime sleepiness in regular heavy snorers. Chest 1991;99:40–48Google Scholar
  55. 55.
    ResMed. AutoSet Portable 2 Plus Overview and Interpretation Guide. San Diego, CA. Res Med. 1998Google Scholar
  56. 56.
    Gugger M. Comparison of ResMed AutoSet (version 3.03) with polysomnography in the diagnosis of the sleep apnoea/hypopnoea syndrome. Eur Respir J 1997;10:587–591Google Scholar
  57. 57.
    Exar EN, Collop NA. The upper airway resistance syndrome. Chest 1999;115:1127–1139Google Scholar
  58. 58.
    Ayappa I, Norman RG, Krieger AC, et al. Non-invasive detection of respiratory effort-related arousals (RERAs) by a nasal cannula/pressure transducer system. Sleep 2000;23:763–771Google Scholar
  59. 59.
    Liam CK. A portal recording system for the assessment of patients with sleep apnoea syndrome. Med J Malaysia 1996;51:82–88Google Scholar
  60. 60.
    Guilleminault C, Palombini L, Poyares D. Chronic insomnia, postmenopausal women, and sleep-disordered breathing. Part 1. Frequency of sleep-disordered breathing in a cohort. J Psychosom Res 2002;53:611–615Google Scholar
  61. 61.
    Guilleminault C, Palombini L, Poyares D, Chowdhuri S. Chronic insomnia, postmenopausal women and sleep-disordered breathing. Part 2. Comparison of nondrug treatment trials in normal breathing and UARS postmenopausal women complaining of chronic insomnia. J Psychosom Res 2002;53:617–623Google Scholar
  62. 62.
    Grunstein R, Sullivan C. Continuous positive airway pressure for sleep breathing disorders In: Kryger MH, Roth T, Dement WC, Principles and Practice of Sleep Medicine. 3rd ed. Philadelphia, WB Saunders Co. 2000. 894–912Google Scholar
  63. 63.
    McGregor P, Thorpy MJ, Schmidt-Nowara WW, Ledereich PS, Snyder M. T-sleep: an improved method for scoring breathing-disordered sleep. Sleep 1992;15:359–363Google Scholar
  64. 64.
    Bastien CH, Vallieres A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med 2001;2:297–307Google Scholar
  65. 65.
    Weaver TE, Laizner AM, Evans LK, et al. An instrument to measure functional status outcomes for disorders of excessive sleepiness. Sleep 1997;20:835–843Google Scholar
  66. 66.
    Buysse D, Reynolds C, III, Monk T, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res 1989;28:193–213Google Scholar
  67. 67.
    Morin CM, Blais F, Savard J. Are changes in beliefs and attitudes about sleep related to sleep improvements in the treatment of insomnia?. Behav Res Ther 2002;40:741–752Google Scholar
  68. 68.
    Morin CM, Colecchi C, Stone J, Sood R, Brink D. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA 1999;281:991–999Google Scholar
  69. 69.
    Saletu B, Klosch G, Gruber G, et al. First-night-effects on generalized anxiety disorder (GAD)-based insomnia: laboratory versus home sleep recordings. Sleep 1996;19:691–697Google Scholar

Copyright information

© Thieme Medical Publishers, Inc. 2004

Authors and Affiliations

  • Barry Krakow
    • 1
    • 2
    • 3
    • 4
    • 6
  • Dominic Melendrez
    • 1
  • Samuel A. Lee
    • 1
  • Teddy D. Warner
    • 2
    • 3
    • 5
  • Jimmy O. Clark
    • 1
  • David Sklar
    • 2
    • 4
  1. 1.Sleep and Human Health InstituteAlbuquerque
  2. 2.University of New Mexico Health Sciences CenterAlbuquerque
  3. 3.Department of PsychiatryUniversity of New Mexico School of MedicineAlbuquerque
  4. 4.Department of Emergency MedicineUniversity of New Mexico School of MedicineAlbuquerque
  5. 5.Institute of EthicsUniversity of New Mexico Health Sciences CenterAlbuquerque
  6. 6.Sleep and Human Health InstituteAlbuquerque

Personalised recommendations