Insomnia and Anxiety (Series in Anxiety and Related Disorders) (13 page)

the Internet (i.e., guided self-hypnosis) to help adults with a fear of the dark. One

reason for the relative absence of scientific accounts may be a stigma attached to

acknowledging a persisting fear typically associated with childhood. Turning off the

lights has been shown to increase arousal and fear, and facilitate an exaggerated

startle response in adults (Grillon, Pellowski, Merikangas, & Davis, 1997), and such

reactivity appears to relate to the common fear of the dark seen in children (Grillon

et al., 1997). It would be interesting to investigate whether turning off the lights is a

mechanism for hyperarousal in insomnia. If a stimulus such as darkness elicits

heightened anxiety, this would be expected to interfere with normal sleep onset.

Somniphobia, the fear of sleep, is one specific phobia sometimes associated with

general sleep difficulty or insomnia. There are several sleep disorders that could

lead to a fear of sleep. The frightening sensorimotor experiences characteristic of

sleep paralysis or hypnagogic hallucinations could cause a fear of sleep to develop.

Although published papers on “fear of sleep” as a phobia are currently lacking, this

References

45

construct is often invoked to explain sleep-avoidant behaviors. PTSD sufferers will

often show a fear of sleep and sleep avoidance in reaction to their chronic disturb-

ing nightmares. Likewise, psychophysiologic insomnia sufferers may also manifest

“fear of sleep” or emotional reactivity to their impending bedtime. Indeed, one

criterion for the diagnosis of psychophysiologic insomnia in the International

Classification of Sleep Disorders, Diagnostic and Coding Manual is heightened

anxiety about sleep (American Academy of Sleep Medicine, 2005). Some insomnia

sufferers begin to “dread” sleep because of the repeated negative emotional experi-

ence of not being able to sleep. This conditioning process is seen as a key etiologic

factor for many insomnia sufferers. CBT strategies such as stimulus control and

cognitive therapy (detailed in Chaps. 7 and 8) target conditioned arousal and fears

about sleep and, thus, may be effective in such cases.

Summary

Insomnia as a symptom is a feature of many anxiety disorders. Insomnia can also

be an important comorbid condition in anxiety disorders. There can be subjective

complaints and EEG-verified sleep disturbances across the range of Anxiety

Disorders. Sleep problems may be most prevalent in those with GAD and PTSD.

There is no real impediment to treating the insomnia of those with anxiety disor-

ders, although there may be some special treatment considerations for panic dis-

order (i.e., allowing for a less conservative time-in-bed restriction) and PTSD (i.e.,

addressing nightmares). There is some evidence that treating the comorbid anxiety

disorder only (and thus ignoring the insomnia) may limit the degree of anxiety

disorder treatment response and/or result in residual insomnia. A combined

approach requires more investigation, but preliminary studies have been

promising.

References

American Academy of Sleep Medicine. (2005).
International classification of sleep disorders-

second edition (ICSD-2). International Classification of Sleep Disorders Steering Committee,

P. J. Hauri (Chairman)
. Chicago.

American Psychiatric Association. (1997).
Diagnostic and Statistical Manual of Mental Disorders,

4th Edition,Text Revision (DSM-IV-TR)
(4th ed.). Washington: DC: American Psychiatric

Association.

Angst, J., Gamma, A., Endrass, J., Goodwin, R., Ajdacic, V., Eich, D., et al. (2004).
European

Archives of Psychiatry and Clinical Neuroscience, 254
(3), 156–164.

Antony, M., & Barlow, D. H. (2002). Specific phobias. In D. H. Barlow (Ed.),
Anxiety and Its

Disorders
(Vol. 2, pp. 380–417). New York: The Guilford Press.

Beesdo, K., Bittner, A., Pine, D., Stein, M., Höfler, M., Lieb, R., et al. (2007). Incidence of social

anxiety disorder and the consistent risk for secondary depression in the first three decades of

life.
Archives of General Psychiatry, 64
(8), 903–912.

46

3 Anxiety Disorders and Accompanying Insomnia

Belanger, L., Morin, C. M., Langlois, F., & Ladouceur, R. (2004). Insomnia and generalized anxi-

ety disorder: Effects of cognitive behavior therapy for GAD on insomnia symptoms.
Journal

of Anxiety Disorders, 18
, 561–571.

Borkovec, T. D. (1982). Insomnia.
Journal of Consulting and Clinical Psychology, 50
, 880–895.

Breslau, N., Roth, T., Burduvali, E., Kapke, A., Schultz, L., & Roehrs, T. (2004). Sleep in lifetime

posttraumatic stress disorder: a community-based polysomnographic study.
Archives of

General Psychiatry, 61
, 508–516.

Brown, T., Black, B., & Uhde, T. (1994). The sleep architecture of social phobia.
Biological

Psychiatry, 35
(6), 420–421.

Brown, T. M., & Uhde, T. W. (2003). Sleep panic attacks: a micro-movement analysis.
Depression

and Anxiety, 18
, 214–220.

Buysse, D., Ancoli-Israel, S., Edinger, J., Lichstein, K., & Morin, C. (2006). Recommendations

for a standard research assessment of insomnia.
Sleep, 29
(9), 1155–1173.

Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh

Sleep Quality Index: A new instrument for psychiatric practice and research.
Psychiatry

Research, 28
, 193–213.

Cairney, J., McCabe, L., Veldhuizen, S., Corna, L., Streiner, D., & Herrmann, N. (2007).

Epidemiology of social phobia in later life.
American Journal of Psychiatry, 15
(3), 224–233.

Calhoun, P., Bosworth, H., Grambow, S., Dudley, T., & Beckham, J. (2002). Medical service uti-

lization by veterans seeking help for posttraumatic stress disorder.
American Journal of

Psychiatry, 159
, 2081–2086.

Cameron, O. G., & Thyer, B. A. (1985). Treatment of pavor nocturnus with alprazolam.
Journnal

of Clinical Psychology, 46
, 405.

Cervena, K., Matousek, M., Prasko, J., Brunovsky, M., & Paskova, B. (2005). Sleep disturbances

in patients treated for panic disorder.
Sleep Medicine Reviews, 6
, 149–153.

Craske, M. G., & Barlow, D. H. (1989). Nocturnal panic.
Journal of Nervous and Mental Disease,

177
, 160–167.

Craske, M. G., Lang, A. J., Aikins, D., & Mystkowski, J. L. (2005).
Behavior Therapy, 36
,

43–54.

Craske, M. G., Lang, A. J., Mystkowski, J. L., Zucker, B. G., Bystritsky, A., & Yan-Go, F. (2002).

Does nocturnal panic represent a more severe form of panic disorder?
Journal of Nervous and

Mental Disease, 190
, 611–618.

Craske, M. G., Lang, A. J., & Rowe, M. (2002). Pre-sleep attributions about arousal during sleep.

Journal of Abnormal Psychology, 111
, 53–62.

Craske, M. G., Lang, A. J., Tsao, J. C. I., Mystkowski, J. L., & Rowe, M. K. (2001). Reactivity to

interoceptive cues in nocturnal panic.
Journal of Behavior Therapy and Experimental

Psychiatry, 32
, 173–190.

Culpepper, L. (2002). Generalized anxiety disorder in primary care: emerging issues in manage-

ment and treatment.
The Journal of Clinical Psychiatry, 63
(Suppl. 8), 35–42.

Dagan, Y., Lavie, P., & Bleich, A. (1991). Elevated awakening thresholds in sleep stage 3–4 in

war-related post-traumatic stress disorder.
Biological Psychiatry, 30
, 618–622.

Dow, B. M., Kelsoe, J., & Gillin, J. (1996). Sleep and dreams in Vietnam PTSD and depression.

Biological Psychiatry, 39
, 42–50.

Edinger, J. D., Bonnet, M., Bootzin, R. R., Doghramji, K., Dorsey, C. M., Espie, C. A., et al.

(2004). Derivation of research diagnostic criteria for insomnia: Report on an American

Academy of Sleep Medicine work group.
Sleep, 27
, 1567–1596.

Edinger, J. D., & Radtke, R. A. (1993). Use of in vivo desensitization to treat a patient’s claustro-

phobic response to nasal CPAP.
Sleep, 16
(7), 678–680.

Eisen, J., Goodman, W., Keller, M., Warshaw, M., DeMarco, L., Luce, D., et al. (1999). Patterns

of remission and relapse in obsessive-compulsive disorder: a 2-year prospective study.
Journal

of Clinical Psychiatry, 60
(5), 346–351.

Espie, C., Broomfield, N., MacMahon, K., Macphee, L., & Taylor, L. M. (2006). The attention-

intention-effort pathway in the development of psychophysiologic insomnia: a theoretical

review.
Sleep Medicine Reviews, 10
(4), 215–245.

References

47

Fireman, B., Koran, L., Leventhal, J., & Jacobson, A. (2001). The prevalence of clinically recog-

nized obsessive-compulsive disorder in a large health maintenance organization.
American

Journal of Psychiatry, 158
(11), 1904–1910.

Fisk, J. D., Ritvo, P. G., Ross, L., Haase, D. A., Marrie, T. J., & Schlech, W. F. (1994). Measuring

the functional impact of fatigue: Initial Validation of the Fatigue Impact Scale.
Clinical

Infectious Diseases, 18
(Suppl 1), S79–S83.

Forbes, D., Phelps, A., & McHugh, T. (2001). Treatment of combat-related nightmares using

imagery rehearsal therapy: a pilot study.
Journal of Traumatic Stress, 14
(2), 433–442.

Fuller, K. H., Waters, W. F., Binks, P. G., & Anderson, T. (1997). Generalized anxiety and sleep

architecture: a polysomnographic investigation.
Sleep, 20
, 370–376.

Grant, B., Hasin, D., Blanco, C., Stinson, F., Chou, S., Goldstein, R., et al. (2005). The epidemiol-

ogy of social anxiety disorder in the United States: Results from the National Epidemiologic

Survey on Alcohol and Related Conditions.
Journal of Clinical Psychiatry, 66
(11), 1351.

Grillon, C., Pellowski, M., Merikangas, K. R., & Davis, M. (1997). Darkness facilitates the acous-

tic startle reflex in humans.
Biological Psychiatry, 42
(6), 453–460.

Gross, R., & Borkovec, T. (1982). Effects of cognitive intrusion manipulation on the sleep onset

latency of good sleepers.
Behaviour Therapy, 13
, 112–116.

Hantouche, E., Bouhassira, M., Lancrenon, S., Ravily, V., & Bourgeois, M. (1995). Prevalence of

obsessive-compulsive disorders in a large French patient population in psychiatric consulta-

tion.
Encephale, 21
(5), 571–580.

Harvey, A. G., & Greenall, E. (2003). Catastrophic worry in primary insomnia.
Journal of

Behavior Therapy Experimental Psychiatry, 34
(1), 11–23.

Hoge, C. W., Castro, C., Messer, S., McGurk, D., Cotting, D., & Koffman, R. (2004). Combat duty

in Iraq and Afghanistan, mental health problems, and barriers to care.
New England Journal

of Medicine, 351
, 13–22.

Hohagen, F., Lis, S., Krieger, S., Winkelmann, G., Riemann, D., Fritsch-Montero, R., et al. (1994).

Sleep EEG of patients with obsessive-compulsive disorder.
European Archives of Psychiatry

and Clinical Neuroscience, 243
(5), 273–278.

Hurwitz, T., Mahowald, M., Kuskowski, M., & Engdahl, B. (1998). Polysomnographic sleep is

not clinicall impaired in Vietnam combat verterans with chronic posttraumatic stress disorder.

Biological Psychiatry, 44
, 1066–1073.

Insel, T., Gillin, J., Moore, A., Mendelson, W., Loewenstein, R., & Murphy, D. (1982). The sleep

of patients with obsessive-compulsive disorder.
Archives of General Psychiatry, 39
(12),

1372–1377.

Kamath, P., Reddy, Y. C., & Kandavel, T. (2007). Suicidal behavior in obsessive-compulsive dis-

order.
Journal of Clinical Psychiatry, 68
(11), 1741–1750.

Kessler, R., Berglund, P., Bruce, M., Koch, J., Laska, E., Leaf, P., et al. (2001). The prevalence

and correlates of untreated serious mental illness.
Health Services Research, 36
, 987–1007.

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005).

Lifetime prevalence and age of DSM-IV disorders in the National Comorbidity Survey

Replication.
Archives of General Psychiatry, 62
(6), 593–602.

Kluge, M., Schüssler, P., Dresler, M., Yassouridis, A., & Steiger, A. (2007). Sleep onset REM

periods in obsessive compulsive disorder.
Psychiatry Research, 152
(1), 29–35.

Kluge, M., Schüssler, P., Künzel, H., Dresler, M., Yassouridis, A., & Steiger, A. (2007). Increased

nocturnal secretion of ACTH and cortisol in obsessive compulsive disorder.
Journal of

Psychiatry Research, 41
(11), 928–933.

Kobayashi, I., Boarts, J. M., & Delahanty, D. L. (2007). Polysomnographically measured sleep

abnormalities in PTSD: A meta-analytic review.
Psychophysiology, 44
(4), 660–669.

Krakow, B., Hollifield, M., Schrader, R., Koss, M., Tandberg, D., & Lauriello, J. (2000). A con-

trolled study of imargery rehearsal for chronic nightmares in sexual assault survivors with