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When sleep apnea mimics psychopathology

Vol. 3, No. 2 / February 2004

Symptoms of obstructive sleep apnea (OSA) often mimic psychopathology. Because of this, patients with OSA who exhibit these symptoms often are misdiagnosed as having a psychiatric disorder.

Consider OSA in the differential diagnosis of:

  • depression. Sleep-disordered breathing is five times more prevalent in adults and children with depression than in nondepressed patients. Psychotic features also positively correlate with OSA.1
  • anxiety. Physiologic and hormonal changes associated with OSA can cause panic attacks.
  • attention-deficit/hyperactivity disorder (ADHD). Attention, concentration, and vigilance are often impaired in adults and children with OSA. Up to one-third of children with frequent, loud snoring display inattention and hyperactivity.2
  • memory impairment. Deficits in working and long-term episodic memory are common in OSA.
  • executive dysfunction. Patients with OSA often cannot sustain an organized, goal-directed, flexible approach to problem solving.
  • erectile dysfunction. Pathologic processes activated by OSA may predispose men to impaired erectile function.3
  • School phobia. Poor academic functioning is common in children with OSA. These children resist going to school because of a resultant loss of self-esteem. Excessive daytime sleepiness also contributes to poor academic performance.2
  • Behavioral problems in children. Sleep deprivation often manifests as irritability and oppositional behavior.

Disturbances in intellectual and executive functioning are strongly correlated with hypoxemia. Deficits in vigilance, alertness, and memory correlate with measures of sleep fragmentation.4

When to suspect sleep apnea

Refer patients to a pulmonologist, ENT specialist, or sleep disorders center if the history and physical exam reveal excessive daytime sleepiness, frequent nocturia, morning headaches, nasal quality to the voice, enlarged tonsils and adenoids in children, or loud snoring or gasping sounds during sleep (consider interviewing the patient’s bed partner).

Risk factors such as family history, recessed chin, smoking, neck size >16 inches, male gender, enlarged tonsils and adenoids, and age >40 may also point to OSA. Also watch for:

  • ethnicity. OSA is most prevalent among Pacific Islanders, Hispanics, and African-Americans.
  • BMI >25 in adults younger than age 65. However, OSA is often missed in young people who are not obese.


1. Obayon M. The effects of breathing-related sleep disorders on mood disturbances in the general population. J Clin Psychiatry 2003;64:1195-1200.

2. O’Brien L, Gozal D. Behavioural and neurocognitive implications of snoring and obstructive sleep apnoea in children: facts and theory. Paediatr Respir Rev 2002;3:3-9.

3. Arruda-Olson AM, Olson LJ, Nehra A, Somers VK. Sleep apnea and cardiovascular disease. Implications for understanding erectile dysfunction. Herz 2003;28:298-303.

4. Salorio C, White D, Piccirillo J, et al. Learning, memory and executive control in individuals with obstructive sleep apnea syndrome. J Clin Exp Neuropsychol 2002;24:93-100.

Dr. Lundt is an affiliate faculty member, Idaho State University, Pocatello. She practices psychiatry in Boise.

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