Sleep Apnea Awareness Week 2026: When Sleep Apnea Doesn’t Come Alone
Sleep Apnea Awareness Week: April 18-26, 2026
Every April, Sleep Apnea Awareness Week invites us to look more closely at one of the most common — and most commonly overlooked — health conditions in the world. Obstructive sleep apnea (OSA) affects an estimated one billion people globally. Yet the majority remain undiagnosed, untreated, and unaware that the exhaustion, the mood swings, the morning headaches, and the restless nights they have come to accept as normal are not normal at all.
This year, Upward Behavioral Health is joining that conversation with a focus that goes deeper than awareness alone: what happens when sleep apnea does not come by itself? Because for a significant number of people living with OSA, the condition does not arrive in isolation. It arrives with insomnia. It arrives with nightmares. It arrives as a constellation of sleep disturbances that interlock, amplify one another, and demand a treatment approach that is just as layered as the problem itself.
Sleep apnea is not always a solo diagnosis. For millions, it arrives alongside insomnia, nightmares, and complex sleep disruption that requires specialized, coordinated care.
Understanding Obstructive Sleep Apnea: More Than Snoring
Obstructive sleep apnea occurs when the muscles at the back of the throat relax during sleep, causing the airway to narrow or close entirely. This triggers a momentary pause in breathing — which can happen dozens or even hundreds of times per night. The brain detects the drop in oxygen and jolts the sleeper awake just enough to reopen the airway, often without the person ever remembering it.
The result is a night filled with fragmented, non-restorative sleep, even if the person believes they slept the recommended 7-9 hours. Over time, the consequences extend well beyond daytime tiredness. Untreated OSA is associated with:
•Elevated blood pressure and increased cardiovascular disease risk
•Type 2 diabetes and metabolic disruption
•Depression and anxiety
•Cognitive impairment and increased dementia risk
•Motor vehicle and workplace accidents from impaired alertness
These are not minor inconveniences. They are serious, life-altering health outcomes that can be meaningfully reduced with proper diagnosis and treatment. And yet, an estimated 80 percent of OSA cases go undiagnosed. The reasons are complex — but one of the most important is that we have not always been looking in the right places, or for the right people.
The Diagnosis Gap: Why Women Are Being Left Behind
For decades, the clinical picture of obstructive sleep apnea was drawn almost exclusively from research conducted in men. The “typical” OSA patient was understood to be a middle-aged, overweight man who snored loudly and woke his partner. Sleep studies were designed around this profile. Referral criteria were built around this profile. And because of this, an entire population of people with OSA — primarily women — fell through the diagnostic gaps.
Women are significantly underdiagnosed with obstructive sleep apnea. Research consistently shows that women with OSA present differently than men. Rather than the classic loud snoring and witnessed breathing pauses, women are more likely to report:
•Chronic fatigue and persistent exhaustion that does not improve with more sleep
•Insomnia — difficulty falling asleep, staying asleep, or both
•Frequent nightmares and disturbing dreams
•Morning headaches
•Frequent nighttime urination
•Mood disturbances, including depression and anxiety
•Brain fog and difficulty concentrating
These symptoms are real. They are also frequently attributed to something else entirely — stress, depression, anxiety, perimenopause, thyroid issues, or simply the demands of daily life. Women are often told they are "just tired" or that their sleep complaints are emotional in nature. By the time many women receive an OSA diagnosis, they have often spent years seeking answers elsewhere.
Women’s OSA symptoms — insomnia, fatigue, nightmares, and mood changes — are frequently misattributed to stress or mental health conditions, delaying diagnosis by years.
Hormonal factors also play a critical role. The risk of OSA rises substantially during pregnancy, when weight gain and fluid retention increase pressure on the airway. It rises again after menopause, when changes in hormone impact airway muscle tone — makes airway collapse during sleep more likely. Women with polycystic ovary syndrome (PCOS) also face elevated OSA risk.
The consequences of this diagnostic delay are serious. Studies have found that women with undiagnosed OSA face a disproportionately high risk of cardiovascular disease relative to men with the same severity of apnea. The bias in our diagnostic systems is not just a matter of fairness — it is a matter of lives.
During Sleep Apnea Awareness Week, we want to say clearly: if you are a woman who is exhausted no matter how much you sleep, who wakes unrefreshed, who struggles with insomnia, nightmares, or mood that you cannot explain — please ask your provider about sleep apnea. And if your provider has not considered it, push for a referral. You deserve a complete evaluation.
COMISA: When Insomnia and Sleep Apnea Coexist
One of the most important and underrecognized developments in sleep medicine over the past decade is the formal recognition of COMISA — comorbid insomnia and obstructive sleep apnea. COMISA describes the condition in which a person has both clinical insomnia and OSA simultaneously, and it is far more common than many clinicians and patients realize.
Research suggests that approximately 30 to 50 percent of people with obstructive sleep apnea also meet criteria for insomnia. That means for millions of people, the problem is not one sleep disorder — it is two, interacting with and worsening each other in a feedback loop that standard treatment for either condition alone may not adequately address.
Insomnia, in this context, is not simply "trouble sleeping." Clinical insomnia is characterized by persistent difficulty initiating sleep, maintaining sleep, or waking too early, combined with significant daytime impairment — and it occurs despite adequate opportunity and circumstances for sleep.
In COMISA, the two conditions reinforce one another:
•OSA disrupts sleep architecture:
The repeated micro-arousals caused by apnea events prevent the brain from spending adequate time in restorative sleep stages. Over time, this erratic pattern of awakening can condition the brain to become hypervigilant during the night — making it harder to fall asleep and stay asleep even on nights when breathing is better.
•Insomnia may increase upper airway vulnerability:
Sleep deprivation and fragmented sleep weaken the neuromuscular control of the upper airway. This means that the chronic sleep loss caused by insomnia can actually worsen OSA severity — creating a cycle that is self-perpetuating and self-amplifying.
•CPAP therapy becomes harder to tolerate:
Continuous positive airway pressure (CPAP) is the gold-standard treatment for OSA. But for people with COMISA, initiating CPAP can be particularly difficult. Insomnia makes it harder to fall asleep with a mask and machine, and the anxiety around sleep that often accompanies insomnia can be exacerbated by the new demands of CPAP use.
COMISA is not simply two conditions that happen to coexist. It is a distinct clinical presentation in which each disorder actively worsens the other — and it requires treatment that addresses both.
The good news is that effective, evidence-based treatment for COMISA exists. Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line, non-pharmacological treatment for insomnia and has been shown to be effective even in the presence of sleep apnea. In many cases, addressing the insomnia component with CBT-I actually improves CPAP adherence, as patients learn to approach sleep with less anxiety and their hyperarousal decreases. Treating OSA with CPAP, in turn, may reduce some of the sleep fragmentation that was feeding the insomnia.
The key is recognizing that COMISA is a specific clinical situation that requires both arms of treatment to be considered, coordinated, and delivered. Treating only the apnea without addressing the insomnia — or vice versa — is likely to leave patients significantly undertreated.
COMISA-mares: The Triad of Nightmares, Insomnia, and Obstructive Sleep Apnea
For some individuals, the clinical picture becomes even more complex. Beyond the intersection of insomnia and OSA, there is a third element that frequently enters the picture and is even less often recognized or treated: nightmares.
We use the term COMISA-mares to describe this triad — the co-occurrence of nightmares, obstructive sleep apnea, and insomnia. It is a formulation that we find clinically meaningful because it names something that many patients experience but rarely see reflected in their care.
Nightmares are not simply unpleasant dreams. Clinically significant nightmares — those that are vivid, distressing, recurrent, and disruptive to sleep — are a recognized sleep disorder in their own right, and they interact with both OSA and insomnia in important ways.
The connection between OSA and nightmares is in part physiological. When an apnea event occurs, oxygen levels in the blood drop. The brain detects this as a threat and creates an arousal to restart breathing. When this happens during REM sleep, the stage in which most vivid dreams and nightmare occur, the result is an awakening in which frightening, disturbing dream content is recalled. Many patients who present for nightmare treatment have never been evaluated for OSA — and in some cases, treating the apnea substantially reduces nightmare frequency.
The connection between insomnia and nightmares is bidirectional. Nightmares cause arousals from sleep, which fragment sleep architecture and contribute to insomnia. At the same time, the anxiety and hyperarousal that characterize insomnia can increase the emotional intensity and frequency of nightmares. People who dread sleep because they fear nightmares develop hyperarousal making it more difficult to sleep. This is the same hyperarousal seen in clinical insomnia.
COMISA-mares — the triad of nightmares, insomnia, and obstructive sleep apnea — represents one of the most complex and undertreated presentations in sleep medicine. Each element feeds the others. All three must be assessed and addressed.
In the COMISA-mares presentation, the three conditions create a particularly vicious cycle. OSA disrupts REM sleep creating awakenings allowing for the recall of nightmares. Nightmares on their own cause awakenings that worsen insomnia. Insomnia increases arousal and emotional reactivity, intensifying nightmares and worsening upper airway tone. The sleep architecture becomes progressively more fragmented, the person’s relationship with sleep becomes increasingly adversarial, and the daytime consequences — fatigue, mood dysregulation, cognitive impairment, hypervigilance — compound.
Effective treatment for COMISA-mares requires expertise across multiple modalities: sleep medicine to evaluate and treat OSA, CBT-I to address the insomnia, and Cognitive Behavioral Therapy for Nightmares (CBT-N) to reduce nightmare frequency and distress. No single provider or single specialty can adequately address all three arms of this triad alone.
Why a Collaborative Treatment Team Matters
The complexity of COMISA and COMISA-mares underscores a fundamental truth about sleep health: it does not fit neatly into a single specialty. Sleep medicine providers — typically pulmonologists, neurologists, or otolaryngologists with sleep fellowship training — are experts in diagnosing and managing the physiological dimensions of sleep disorders. They conduct or interpret sleep studies, prescribe and manage CPAP and other PAP therapies, evaluate oral appliance candidacy, and monitor the medical consequences of untreated OSA.
But the behavioral and psychological dimensions of sleep disorders — the insomnia, the nightmares, the hyperarousal, the dysfunctional beliefs about sleep, the CPAP anxiety — require a different expertise. This is where behavioral sleep medicine providers play an indispensable and often underutilized role.
Behavioral sleep medicine (BSM) is a specialty focused on the psychological and behavioral treatment of sleep disorders. BSM providers — typically psychologists or other mental health professionals with specialized training in sleep — are trained to deliver interventions such as:
•CBT-I (Cognitive Behavioral Therapy for Insomnia) — the gold-standard, non-medication treatment for chronic insomnia
•CBT-N (Cognitive Behavioral Therapy for Nightmares)- the gold-standard, non-medication treatment for nightmares
•CPAP adherence support and desensitization for mask anxiety
•Sleep and nightmare education grounded in behavioral principles rather than generic advice
•Assessment and treatment of co-occurring psychological conditions that affect sleep, including PTSD, anxiety disorders, and depression
When sleep medicine and behavioral sleep medicine providers work collaboratively — sharing information, coordinating care, and treating the full picture of a patient’s sleep health — outcomes improve substantially. CPAP adherence increases when insomnia and anxiety are addressed. Insomnia treatment is more effective when OSA has been identified and managed. Nightmare treatment is more durable when underlying apnea is no longer fragmenting REM sleep.
A sleep medicine provider and a behavioral sleep medicine provider working together are greater than the sum of their parts. Collaborative care is not a luxury — for complex sleep presentations, it is the standard of care.
Upward Behavioral Health: Specializing in What Others Miss
At Upward Behavioral Health, we have built our practice around the recognition that sleep disorders — especially insomnia and nightmares — rarely exist in isolation. Our behavioral sleep medicine providers are trained specifically to screen for, assess, and treat the full spectrum of sleep disturbances, with particular expertise in the comorbid presentations that too often fall through the cracks of standard care.
When a patient comes to us with insomnia, we do not assume that insomnia is the only issue. We screen for obstructive sleep apnea. We ask about nightmares and trauma. We consider whether the presentation might reflect COMISA or COMISA-mares. We are trained to recognize that exhaustion in a woman may not be “just stress” — it may be a sleep disorder that has been missed for years.
And because we believe in collaborative care, we do not work in silos. We communicate with our patients’ sleep medicine providers, primary care physicians, and other specialists to ensure that treatment plans address all dimensions of a patient’s sleep health. When a patient needs CPAP but is struggling to tolerate it, we provide behavioral support. When a patient is receiving CBT-I but also has nightmares that are not resolving, we add nightmare-focused treatment. When a patient’s OSA is well-managed but their insomnia persists, we dig into the behavioral patterns and beliefs that are maintaining the sleeplessness.
This approach — comprehensive, collaborative, and attentive to the complexity of each person’s experience — is what we believe sleep care should look like.
What to Do If You Recognize Yourself in This
Sleep Apnea Awareness Week exists because awareness saves lives. If you have read this far and recognized yourself — or someone you love — in any part of this conversation, here is what we encourage you to do:
1. Talk to your doctor about sleep apnea.
Do not assume that because you do not snore loudly or because you are a woman or because you are not overweight, OSA is not relevant to you. Ask your provider whether a home sleep test or an in-lab polysomnography might be appropriate. Advocate for a complete evaluation.
2. Take insomnia and nightmares seriously.
These are not character flaws or signs of weakness. They are medical conditions with effective, evidence-based treatments. If you have been managing chronic insomnia with medication alone, or simply enduring it, know that CBT-I and CBT-N offer lasting relief without the side effects and dependency risks of sleep medications.
3. Seek care that sees the whole picture.
If you suspect you may have COMISA or COMISA-mares, look for providers who are trained to recognize and treat these presentations. A sleep medicine provider and a behavioral sleep medicine provider working together give you the best chance of meaningful, durable improvement.
4. Reach out to Upward Behavioral Health.
Our behavioral sleep medicine specialists are here to help. Whether you are struggling with insomnia, nightmares, CPAP adherence, or a complex combination of sleep challenges, we have the training and the commitment to provide care that meets you where you are. We screen carefully, treat collaboratively, and stay in the conversation with your broader care team.
Sleep Apnea Awareness Week: A Moment to Look Deeper
This week is more than an opportunity to share statistics about sleep apnea. It is an invitation to look more honestly at the ways sleep disorders present, persist, and are missed — and to build systems of care that are genuinely adequate to the complexity of what people experience.
It is an invitation to see the woman who cannot explain her exhaustion not as someone who needs to manage her stress better, but as someone who deserves a thorough sleep evaluation.
It is an invitation to see the person who lies awake for hours before falling asleep, who wakes repeatedly in the night and cannot get back to sleep, who wakes from vivid and terrifying dreams not as someone with a ‘simple’ sleep complaint, but as someone who may be living with COMISA-mares and who deserves care that addresses all three dimensions of their suffering.
It is an invitation to build treatment teams where sleep medicine and behavioral sleep medicine providers know each other, talk to each other, and treat their shared patients as whole people with complex, interconnected needs.
Sleep is not a luxury. Restorative, safe, and peaceful sleep is a foundation of health — and everyone deserves access to care that can actually deliver it.
At Upward Behavioral Health, we are proud to be part of that work. We are proud to stand alongside our colleagues in sleep medicine and to bring our specialized expertise in behavioral sleep medicine to the people who need it most.
This Sleep Apnea Awareness Week, we encourage you to learn, to ask questions, and if you need it — to reach out. You do not have to keep managing alone.