European Sleep Research Society (ESRS) Symposium on Insomnia and Sleep Apnea

I am delighted to announce that on September 15th in Bologna, Italy, the annual European Sleep Research Society (ESRS) will offer a two-hour symposium delving into the important relationships between insomnia and co-morbid obstructive sleep apnea.

Here’s a preview of the symposium:

“Insomnia and obstructive sleep apnea are the two most common sleep disorders (prevalence’s 4-10%). They have been characterized with quite different phenotypes and, perhaps for that reason, been considered independent disorders. However, research now shows a much higher prevalence of co-morbidity (30-60%) than predicted from independent disorders suggesting causal interaction. In any case it presents a significant clinical challenge. The most common treatment of OSA is positive airway pressure (PAP). However, acceptance and adherence rates to this treatment are often disappointing. The presence of co-morbid insomnia may contribute to this adherence problem. Can the insomnia be treated effectively and result in improved PAP treatment adherence and overall treatment outcomes? Conversely, can enhanced PAP technology lead to greater adherence and improved insomnia outcomes? The symposium aims to explore these questions in the attempt to improve outcomes for patients referred to sleep disorder centers around the world.

The speakers and the titles of their talks in the two-hour symposium include:

  1. Christian Guilleminault, USA: “The early recognition of co-morbid obstructive sleep apnea and insomnia”
  2. Barry Krakow, USA: “Positive airway pressure to treat co-morbid insomnia and sleep-disordered breathing: a rationale for advanced auto-adjusting dual pressure technology”
  3. Erla Bjornsdottir, Iceland: “Insomnia phenotypes response to obstructive sleep apnea treatment in co-morbid insomnia/OSA”
  4. Leon Lack, Australia: “Treatment of insomnia before CPAP for co-morbid insomnia/obstructive sleep apnea”

Most people recognize Dr. Guilleminault as one of if not the greatest living sleep researcher in the world, but far fewer people realize that in the early and mid-1970s, he was the first to publish papers connecting sleep-disordered breathing and insomnia. In these cases, he noted central sleep apnea was the predominant finding. In 1973 in Science, he published the first paper to describe sleep apnea as a trigger to awakenings in insomnia patients. He and his co-authors also appear to be the first to note: “An important clinical implication is that patients complaining only of insomnia may be suffering from this syndrome.” (1) His group published two more papers in 1974 and 1976 (2,3), the latter of which contained this prescient quote: “Sleeping pills that are central nervous system depressants should be cautiously prescribed for patients with such syndromes [combination of insomnia and sleep apnea].(3) Thus, it is apparent that these works were way head of their time in so far as connecting the dots between insomnia and sleep apnea. Fast forward to 2008, and they published the first RCT comparing well-known, evidence based treatments in patients with insomnia-sleep apnea, showing that both throat surgery and cognitive-behavioral therapy led to insomnia improvements (4).

In our own work in 2001, we coined the term “complex insomnia” to describe this interconnection between insomnia and sleep-disordered breathing. (5) And, in 2006 we published the first RCT on the topic using an unconventional, conservative, and previously unproven treatment modality (nasal dilator strips), which showed clear-cut clinical improvements for 75% of insomniacs who used the nasal strips compared to the educational control group. (6) Our more recent efforts with the use of ABPAP and ASV therapies for insomniacs will also be discussed at the symposium. (7)

Dr. Björnsdóttir and colleagues published an article in 2012 showing that insomnia was more common in sleep apnea patients compared to a control group from the general population. (8) In a paper in 2013, her research group showed the combination of insomnia-sleep apnea may be associated with greater risk for sick leave compared to each disorder alone. (9) And in their most recent work, they reported two clinically relevant findings: a) insomnia patients using PAP therapy show improvements in middle of the night insomnia but not sleep onset insomnia; and b) early and late (by time of night) insomnia patients with co-occurring sleep apnea show more difficulties adapting to PAP therapy. (10).

Last, Dr. Lack, who organized and will chair the symposium has been a sleep researcher with interests in insomnia dating back to the 1980s and has published numerous papers in various areas of sleep medicine. (11) He is acknowledged internationally as one of the world’s leaders in behavioral, non-drug management of insomnia and has been keenly aware of the important clinical conundrums to address when attempting to treat insomnia in sleep apnea patients.


  1. Guilleminault C, Eldridge FL, Dement WC. Insomnia with sleep apnea: a new syndrome. Science. 1973 Aug 31;181(4102):856-8.
  2. Guilleminault C. Sleep apnoea-insomnia. Nurs Times. 1974 Oct 31;70(44):1708-9.
  3. Guilleminault C, Eldridge FL, Phillips JR, Dement WC. Two occult causes of insomnia and their therapeutic problems. Arch Gen Psychiatry. 1976 Oct;33(10):1241-5.
  4. Guilleminault C, Davis K, Huynh NT. Prospective randomized study of patients with insomnia and mild sleep disordered breathing. Sleep. 2008 Nov;31(11):1527-33.
  5. Krakow B, Melendrez D, Pedersen B, Johnston L, Hollifield M, Germain A, Koss M, Warner TD, Schrader R. Complex insomnia: insomnia and sleep-disordered breathing in a consecutive series of crime victims with nightmares and PTSD. Biol Psychiatry. 2001 Jun 1;49(11):948-53.
  6. Krakow B, Melendrez D, Sisley B, Warner TD, Krakow J, Leahigh L, Lee S. Nasal dilator strip therapy for chronic sleep-maintenance insomnia and symptoms of sleep-disordered breathing: a randomized controlled trial. Sleep Breath. 2006 Mar;10(1):16-28.
  7. Krakow B, Ulibarri VA, Romero E, Thomas RJ, McIver N. Adaptive servo-ventilation therapy in a case series of patients with co-morbid insomnia and sleep apnea. J Sleep Disord Treat Care. 2013;2(1):1-10.
  8. Björnsdóttir E, Janson C, Gíslason T, Sigurdsson JF, Pack AI, Gehrman P, Benediktsdóttir B. Insomnia in untreated sleep apnea patients compared to controls. J Sleep Res. 2012 Apr;21(2):131-8. doi: 10.1111/j.1365-2869.2011.00972.x. Epub 2011 Oct 12.
  9. Sivertsen B, Björnsdóttir E, Øverland S, Bjorvatn B, Salo P. The joint contribution of insomnia and obstructive sleep apnoea on sickness absence. J Sleep Res. 2013 Apr;22(2):223-30. doi: 10.1111/j.1365-2869.2012.01055.x. Epub 2012 Oct 9.
  10. Björnsdóttir E, Janson C, Sigurdsson JF, Gehrman P, Perlis M, Juliusson S, Arnardottir ES, Kuna ST, Pack AI, Gislason T, Benediktsdóttir B. Symptoms of insomnia among patients with obstructive sleep apnea before and after two years of positive airway pressure treatment. Sleep. 2013 Dec 1;36(12):1901-9. doi: 10.5665/sleep.3226.

Barry Krakow MD


Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.

Leave a comment

Comments have to be approved before showing up.