Can anxiety contribute to the development of sleep apnea?

Anxiety and Sleep Apnea: The Relationship and Implications

Anxiety does not directly cause sleep apnea, but it can worsen existing sleep apnea symptoms and create a bidirectional relationship where each condition exacerbates the other.

The Relationship Between Anxiety and Sleep Apnea

Anxiety and sleep apnea have a complex relationship that involves several mechanisms:

How Anxiety Affects Sleep Apnea

• Anxiety can contribute to sleep disruption, which may worsen existing sleep apnea symptoms 1
• Medications used to treat anxiety, particularly benzodiazepines, can potentially worsen obstructive sleep apnea (OSA) by causing relaxation of upper airway muscles 1
• Chronic stress and anxiety may lead to physiological changes that affect sleep architecture and breathing patterns during sleep

How Sleep Apnea Affects Anxiety

• Studies show high prevalence of anxiety symptoms in OSA patients (11-70%) 2, 3
• The severity of OSA (measured by apnea-hypopnea index) is linearly associated with the persistence of anxiety symptoms 4
• For each one-unit increase in AHI (apnea-hypopnea index), there is an 18% increased likelihood of persistent anxiety 4

Risk Factors and Medications That Connect Both Conditions

Medications That May Worsen Sleep Apnea

• Benzodiazepines: While a Cochrane review found no significant worsening of OSA with most sedative drugs, some benzodiazepines (flurazepam and triazolam) significantly lowered nighttime oxygen saturation 1
• Opioids: Cause relaxation of tongue and upper airway muscles, which may exacerbate OSA 1
• Baclofen: May provoke upper airway collapse during sleep and worsen OSA 1
• Medications causing weight gain: Including certain antidepressants (particularly paroxetine), antipsychotics, and antihistamines can indirectly worsen OSA by promoting weight gain 1

Shared Risk Factors

• Obesity is a major risk factor for OSA, with about 70% of OSA patients being obese 1
• Poor sleep hygiene behaviors can contribute to both anxiety and sleep disturbances 1

Diagnostic Considerations

When evaluating patients with anxiety who may have sleep apnea:

• Screen for common OSA symptoms: snoring, observed apneas, excessive daytime sleepiness, morning headaches 1
• Consider using validated screening tools like the STOP questionnaire for OSA risk assessment 1
• Be aware that sleep disturbances are prevalent in 30-75% of patients with anxiety disorders 1
• Evaluate for obstructive sleep apnea when patients with anxiety report:
  • Disrupted sleep patterns
  • Excessive daytime fatigue despite adequate sleep time
  • Worsening anxiety symptoms despite treatment

Treatment Implications

Impact of Treating Sleep Apnea on Anxiety

• CPAP therapy has been shown to significantly decrease anxiety scores in patients with moderate to severe OSA 5
• However, meta-analyses show that while CPAP has a moderate effect on anxiety symptoms, it may not be superior to dental appliances or sham CPAP in some studies 6
• Improvement in subjective symptoms may be partially mediated by patient expectations and healthcare provider contact 6

Treatment Priorities

1. Address both conditions simultaneously:

   • Treat underlying OSA with appropriate interventions (CPAP, weight loss, etc.)
   • Consider anxiety treatments that won't worsen OSA

2. Medication considerations:

   • Avoid benzodiazepines when possible in patients with OSA 1
   • If antidepressants are needed, consider options less likely to cause weight gain (fluoxetine or sertraline rather than paroxetine) 1

3. Non-pharmacological approaches:

   • Sleep hygiene education 1
   • Regular physical activity 1
   • Cognitive behavioral therapy for insomnia (CBT-I) 1

Clinical Pitfalls to Avoid

• Don't assume anxiety is the only cause of sleep problems - always consider OSA, especially in patients with risk factors
• Don't prescribe benzodiazepines without screening for OSA in anxious patients with sleep complaints
• Don't overlook the bidirectional relationship - treating only one condition may result in suboptimal outcomes
• Don't miss OSA in women - there is often a diagnostic bias toward men, but OSA is common in women as well 1
• Remember that CPAP adherence may be challenging in patients with anxiety, particularly those with claustrophobia 3

By addressing both anxiety and potential sleep apnea concurrently, clinicians can help break the cycle where each condition worsens the other, leading to improved outcomes in both morbidity and quality of life.