COMISA HELL? progressing beyond “I can't have CPAP screwing up my sleep right now”

 COMISA HELL? progressing beyond “I can't have CPAP screwing up my sleep right now”

The Problem:

Knowing you need CPAP (Continuous Positive Airway Pressure) because you’ve been diagnosed with OSA, but finding it impossible to cope with it, in the context of existing insomnia, and feeling it ruins any chance of sleep. Why? Because it feels impossible to sleep while you're 100% focused on trying to breathe back against the air blasting up your nose or in your mouth, all night. I'm a sleep psychologist who specialises in helping insomnia sufferers navigate CBTi, or Cognitive Behaviour Therapy for Insomnia.  And in trialling CPAP, I now fully understand how challenging it is to have both insomnia and OSA together. Let me briefly describe for you the start of the journey.

To start, some definitions:

OSA: is a chronic sleep-related breathing disorder that causes the upper airway to collapse during sleep. That is, collapse with partial or full airway closure. It comes with multiple adverse health outcomes: physical, psychological, cognitive. Treatments for OSA include weight loss, continuous positive airway pressure (CPAP), mandibular advancement splints, and upper airway surgery.

CPAP:CPAP is preferred treatment for moderate-severe OSA: it is continuous positive airway pressure that is used to deliver a set pressure to keep otherwise obstructed airways open, that is maintained throughout the respiratory cycle & throughout the night.

Insomnia: is difficulty falling asleep, staying asleep or waking too early, sleep is dissatisfying & causing distress, unrefreshed feelings in the mornings, and work, educational, ie cognitive functioning is impacted. Can be acute, transient, or chronic.

Prevalence: rates of OSA have increased significantly over the last 40 years. Eg. Between 2003 and 2020, OSA prevalence increased from 0.14% to 4.59%. Globally, it’s estimated 1 billion people have OSA, with some countries experiencing rates over 50%. In the elderly the rates may be as high as 90% in these countries.

If you have co-occurring OSA & insomnia, or COMISA, there is immediate internal conflict. That is, immediately your mask is on, the shock of unexpected suffocation occurs, and it feels difficult or even impossible to keep breathing back against the relentless air blasting up your nose or into your mouth. Like trying to sip from a fire hose. And your next thought is that this will be how the whole night unfolds: that it will be impossible to sleep while you use all your concentration to fight all night against the air pressure.

Why exactly is it so problematic? Growing rates of insomnia (NIH:The unadjusted prevalence of insomnia symptoms increased from 15.6% to 17.1% between 2002 and 2012, representing an absolute increase of 1.5%).

AND growing rates of OSA diagnosis BUT:

only 30% CPAP compliance: Because it feels like an impossibility, that you can get sleep and keep the CPAP on, not only in 1 night, but night after night. At first, CPAP use & sleep feel mutually exclusive. No wonder people try it for a few hours then pull it off, thinking "Phew, now I can sleep".

The treatment for co-occurring insomnia & OSA: CBTi for insomnia while doing desensitisation to the CPAP device.

This is how the desensitisation process begins. It's like doing your scuba ticket for the first time and confronting the weirdness of breathing underwater when you've always held your breath.

Using whatever valued Netflix watching or podcasts or audibooks you prefer, you gradually sit with the feelings until you habituate, or get used to, the sensations. And over time the overwhelm & oppressiveness of the airway pressure lessens. Then you start to just "not notice" it.

If you can persevere through the first night, the feeling of agency is the reward in the morning. This can keep you going with it, regardless of any panic feelings about this as a sleep threat longterm. A sleep psychologist can help you with a desensitisation program & doing evidence-based CBTi with you, to help you see the robustness of your sleep amidst the CPAP challenges.

For further information, see my upcoming podcast with HealthEd's Dr David Lim, on navigating co-occurring OSA and insomnia.