Insomnia and Anxiety (Series in Anxiety and Related Disorders) (2 page)

9 Other Issues in Managing the Sleep of Those with Anxiety
.................. 123

Relaxation-Based Strategies ....................................................................... 123

PMR Treatment Outline .............................................................................. 126

Cognitive Behavioral Treatment of Nocturnal Panic .................................. 131

Craske’s Nocturnal Panic Protocol ............................................................. 131

Treating Claustrophobia Associated with Sleep Apnea Treatment ............ 134

Dream/Nightmare Rescripting .................................................................... 138

Is it Time for a Sleep Specialist Consultation? ........................................... 143

References ................................................................................................... 145

Index
................................................................................................................. 149

Chapter 1

Anxiety and Insomnia: An Overview

Abstract
Living chronically with insomnia can generate considerable anxiety and

interfere with the quality of life. Of the most commonly reported health-related

problems, insomnia is rated as among the most frequently reported complaints

(Acta Psychiatrica Scandinavica 96:287–294, 1997). While insomnia is a prevalent,

distressing, and significant disorder in its own right, it is a problem that occurs fre-

quently in the context of another serious psychological disorder. For example, the

presence of insomnia is associated with the eventual development of an Anxiety

Disorder in one quarter of insomnia sufferers (Journal of the American Medical

Association 262:1479–1484, 1989). Both insomnia (Sleep 17:630–637, 1994;

Journal of the American Medical Association 247:997–1103, 1982; American

Journal of Psychiatry 145:346–349, 1988) and anxiety disorders (Journal of

Abnormal Psychology 99:308–312, 1990) often occur with another comorbid

disorder, which would be expected to further compound their costliness. Anxiety

and insomnia exert complex dynamic effects upon each other. It is for this reason

that we write a book for clinicians to understand the overlap and develop effective

treatment strategies to address sleep problems in this context. In this first chapter,

we consider diagnostic considerations for insomnia when it cooccurs with anxiety

symptoms and anxiety disorders and discuss the limitations of viewing insomnia as

a secondary symptom when it cooccurs with other conditions such as anxiety disor-

ders. We also propose a Cognitive Behavioral model of insomnia and anxiety. Thus,

this chapter provides a preliminary introduction to insomnia and the cooccurrence

of anxiety and anxiety disorders, whereas the subsequent chapters provide a more

in-depth exploration of this complex and poorly understood relationship.

It is understandably distressing to experience a sustained impairment in the ability to

initiate or maintain sleep. Living chronically with this condition known as insomnia

can generate considerable anxiety and interfere with the quality of life. Of the most

commonly reported health-related problems, insomnia is rated as among the most

frequently reported complaints (Canals, Domenech, Carbajo, & Blade, 1997).

Prevalence rates for chronic insomnia vary by age and are somewhere between 10%

C.E. Carney and J.D. Edinger,
Insomnia and Anxiety
, Series in Anxiety and Related Disorders,

1

DOI 10.1007/978-1-4419-1434-7_1, © Springer Science+Business Media, LLC 2010

2

1 Anxiety and Insomnia: An Overview

and 20% of the general population (Foley, Monjan, & Brown, 1995; Mellinger,

Balter, & Uhlenhuth, 1985). Although insomnia diagnoses occur across all age

groups, such diagnoses are alarmingly common in middle-aged to older adults

(Ohayon, 2002; Ohayon, Zulley, Guilleminault, Smirne, & Priest, 2001). While

insomnia is a prevalent, distressing, and significant disorder in its own right, it is a

problem that occurs frequently in the context of another serious psychological dis-

order. For example, the presence of insomnia is associated with the eventual develop-

ment of an Anxiety Disorder in one quarter of insomnia sufferers (Ford & Kamerow,

1989). Both insomnia (Buysse et al., 1994; Coleman et al., 1982; Jacobs, Reynolds

III, Kupfer, Lovin, & Ehrenpreis, 1988) and anxiety disorders (Sanderson, Di Nardo,

Rapee, & Barlow, 1990) often occur with another comorbid disorder, which would

be expected to further compound their costliness. For example, those with comorbid

anxiety and insomnia have a poorer reported quality of life than those with anxiety

only (Ramsawh, Stein, Belik, Jacobi, & Sareen, 2009). Anxiety and insomnia symp-

toms and disorders cooccur frequently and exert complex dynamic effects upon each

other. It is for this reason that we write a book for clinicians to understand the overlap

and develop effective treatment strategies to address sleep problems in this context.

In this chapter, we consider diagnostic considerations for insomnia when it

cooccurs with anxiety symptoms and anxiety disorders, and we discuss the limita-

tions of viewing insomnia as a “secondary” symptom when it occurs comorbid to

other conditions such as anxiety disorders. We also propose a Cognitive Behavioral

model of insomnia and anxiety. The purpose of this chapter is to provide a preliminary

introduction to insomnia and the cooccurrence of anxiety and anxiety disorders,

whereas the subsequent chapters provide a more in-depth exploration of this complex

and poorly understood relationship.

What is Insomnia?

Primary Insomnia (PI), in the absence of psychiatric or other medical disorders, is

costly in its own right. For example, it substantially increases health care utilization

and related costs and accounts for as many as 3.5 disability days per month (Hajak

& SINE Study Group Study of Insomnia in Europe, 2001; Simon & VonKorff,

1997; Weissman, Greenwald, Nino-Murcia, & Dement, 1997). PI has been linked

to several other poor outcomes including decreased occupational productivity and

increased occupational accidents, increased alcohol consumption, and a general

sense of poor health-related quality of life (Gislason & Almqvist, 1987; Johnson,

Roehrs, Roth, & Breslau, 1998; Katz & McHorney, 1998). There is a cause for

special concern for insomnia in older adults as insomnia occurs in a staggering 57%

of this age group (Foley et al., 1995), and it is linked to serious falls even after

controlling for age, gender, the use of prescription medications, depression, and

visual or mobility impairments (Brassington, King, & Bliwise, 2000). Given these

considerations, PI warrants timely, effective, and enduring treatment, yet it is well-

documented that insomnia too often goes undetected and untreated (Leger, 2005).

Diagnostic Considerations for Insomnias

3

Diagnostic Considerations for Insomnias

The disorder called Primary Insomnia was first described in the revised, third

edition of the American Psychiatric Association’s Diagnostic and Statistical

Manual – DSM-III-R (American Psychiatric Association, 1987) and remains in the

present-day updated version of this manual (American Psychiatric Association,

1997). The diagnostic criteria require that the sleep complaint (e.g., sleep onset or

sleep maintenance difficulties, or nonrestorative sleep) is predominant, and lasts at

least one month. There are no established cutoffs for how quantitatively disrupted

sleep must be to receive this diagnosis. The convention often employed is that the

time spent awake at the beginning of the sleep period or in the middle of the night

is greater than 30 min, and that such onset or maintenance problems occur three or

more nights per week (Lichstein, Durrence, Taylor, Bush, & Riedel, 2003). Despite

this convention, the DSM has not yet adopted these guidelines. Interestingly, an

attempt to quantify a frequency was unsuccessful because of wide variability in

insomnia complaints (Lineberger, Carney, Edinger, & Means, 2006). Thus, some-

one with insomnia could have only one impressively poor night of sleep (e.g.,

spending 3 or more hours awake on bed once or twice per week), moderately dis-

turbed sleep (e.g., half the nights are characterized by an hour or so of sleep loss),

or frequent mild disruptions (e.g., taking 30 min to fall asleep every night). Unlike

many other sleep disorders (e.g., sleep-disordered breathing, periodic limb move-

ment disorder and some parasomnias), PI is a subjective condition, that is, the

diagnosis can be made from clinical interview and self-reported tools, rather than

expensive overnight polysomnographic studies (American Sleep Disorders

Association, 1995).

In addition to the presence of a subjective sleep complaint, the disturbance must

cause clinically significant distress or impairment in social, occupational, or other

areas of functioning. This criterion would typically reflect one or more of the day-

time symptoms of insomnia listed in the Research Diagnostic Criteria for Insomnia

(Edinger et al., 2004), such as: fatigue/malaise, attention/concentration problems,

negative mood, social/vocational dysfunction or poor school performance, somatic

symptoms such as tension headaches and/or gastrointestinal symptoms in response

to sleep loss, motivation/energy/initiative reduction, daytime sleepiness, and/or

worry about sleep. Whilst some clinicians are not accustomed to thinking about

such symptoms as part of insomnia; in actuality, insomnia is best characterized as

a disorder with manifestations throughout the 24-h period.

The remaining criteria for insomnia relate to exclusions, or differential diagno-

sis. For instance, the insomnia cannot occur
exclusively
during another sleep disor-

der (e.g., narcolepsy, breathing-related sleep disorder, circadian rhythm disorder or

parasomnia), or another mental disorder (e.g., major depressive disorder, Generalized

Anxiety Disorder). Lastly, it cannot be due to the physiologic effects of a substance

(e.g., medication or drug of abuse) or a general medical condition. These criteria

specify that a PI diagnosis is assigned when the insomnia does not occur
exclusively

during the course of another primary sleep or mental disorder and is not the direct

4

1 Anxiety and Insomnia: An Overview

result of a general medical disorder or substance use/abuse. The word exclusively

is important, as it is possible and common to have a comorbid condition accompa-

nying the insomnia. Thus, an insomnia diagnosis can, and should be made in the

presence of another mental, medical, or sleep disorder, if there is a prominent

insomnia complaint that causes distress or impaired functioning. The following

case examples exemplify how individuals with PI and coexisting anxiety disorders

may present clinically:

Mr. B was a 43-year-old professor who complained of sleep onset insomnia for the past 11

years. About 8 years ago, he began suffering from panic attacks. He acknowledged that

there might be some relation between the panic attacks and his insomnia (e.g., he was

occasionally more likely to experience a panic attack after a poor night of sleep). He was

treated with medication and ceased having panic attacks, but his insomnia persisted. The

panic attacks later returned and he continues to suffer from both conditions.

Ms. K was a 23-year-old student who suffered from OCD but denied any relation of this

condition to her sleep. She did not report any nighttime rituals that interfered with her ability

to fall asleep, and she did not appear to be any more likely to sleep poorly on a day, char-

acterized by significant anxiety and compulsive behaviors. There were periods of apparent

remission of obsessions and compulsions, but her sleep problem persisted.

The Case of Comorbid Insomnia: More Nosological Issues

As noted in the previous section, PI can occur seemingly independently from a

coexisting disorder and also can persist during periods of remission from another

coexisting disorder. If the insomnia is a prominent clinically significant complaint

and does not occur
exclusively
during the comorbid disorder, a diagnosis of PI is

made. In cases wherein clinically significant insomnia occurs exclusively within

the context of a cooccurring disorder (i.e., the person is complaining about his/her

sleep and resultant daytime symptoms, and the insomnia waxes and wanes with the

comorbid condition), it may be appropriate to diagnose Insomnia Related to

Another Axis I Disorder (IMD).

The relationship between insomnia and anxiety is complex. Insomnia can cause

anxiety, and experiencing a chronic anxiety problem also can interfere with the ability

to sleep. Inducing worry in nonworrying good sleepers by telling them that they will