Skip to main content

Anxiety and sleep problems: Emerging concepts and theoretical treatment implications

Abstract

The high prevalence and comorbidity of anxiety and sleep problems, especially insomnia, suggest an important underlying relationship between these disorders. In this article, we highlight two theoretical models explaining this co-occurrence, provide a brief update on the association between anxiety-insomnia and anxiety-cataplexy in general, and review more specifically sleep problems in generalized anxiety, post-traumatic stress disorder, and panic disorder. We also explore sleep paralysis as an anxiety-sleep event. Our goal with this examination of selective anxiety-sleep problems is to provide clues about diagnostic and treatment approaches and frame strategies for future research.

This is a preview of subscription content, access via your institution.

References and Recommended Reading

  1. 1.

    Maher MJ, Rego SA, Asnis GM: Sleep disturbances in patients with post-traumatic stress disorder: epidemiology, impact and approaches to management. CNS Drugs 2006, 20:567–590.

    PubMed  Article  CAS  Google Scholar 

  2. 2.

    Spira AP, Friedman L, Aulakh JS, et al.: Subclinical anxiety symptoms, sleep, and daytime dysfunction in older adults with primary insomnia. J Geriatr Psychiatry Neurol 2008, 21:149–153.

    PubMed  Article  Google Scholar 

  3. 3.

    Benca RM: Consequences of insomnia and its therapies. J Clin Psychiatry 2001, 62:33–38.

    PubMed  Google Scholar 

  4. 4.

    Neckelmann D, Mykletun A, Dahl AA: Chronic insomnia as a risk factor for developing anxiety and depression. Sleep 2007, 30:873–880.

    PubMed  Google Scholar 

  5. 5.

    Weissman MM, Greenwald S, Niño-Murcia G, Dement WC: The morbidity of insomnia uncomplicated by psychiatric disorders. Gen Hosp Psychiatry 1997, 19:245–250.

    PubMed  Article  CAS  Google Scholar 

  6. 6.

    Breslau N, Roth T, Rosenthal L, Andreski P: Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Biol Psychiatry 1996, 39:411–418.

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    Ohayon MM, Roth T: Place of chronic insomnia in the course of depressive and anxiety disorders. J Psychiatr Res 2003, 37:9–15.

    PubMed  Article  Google Scholar 

  8. 8.

    Johnson EO, Roth T, Breslau N: The association of insomnia with anxiety disorders and depression: exploration of the direction of risk. J Psychiatr Res 2006, 40:700–708.

    PubMed  Article  Google Scholar 

  9. 9.

    Post RM: Kindling and sensitization as models for affective episode recurrence, cyclicity, and tolerance phenomena. Neurosci Biobehav Rev 2007, 31:858–873.

    PubMed  Article  Google Scholar 

  10. 10.

    Uhde TW, Cortese BM: Anxiety and insomnia: theoretical relationship and future research. In Anxiety in Health Behaviors and Physical Illness. Edited by Zvolensky MJ, Smits JA. New York: Springer; 2008:105–127.

    Chapter  Google Scholar 

  11. 11.

    Anic-Labat S, Guilleminault C, Kraemer HC, et al.: Validation of a cataplexy questionnaire in 983 sleep-disorders patients. Sleep 1999, 22:77–87.

    PubMed  CAS  Google Scholar 

  12. 12.

    Flosnik DL, Cortese BM, Uhde TW: Cataplexy in anxious patients: is subclinical narcolepsy underrecognized in anxiety disorders. J Clin Psychiatry 2009 May 5 (Epub ahead of print).

  13. 13.

    Papadimitriou GN, Linikowski P: Sleep disturbance in anxiety disorders. Int Rev Psychiatry 2005, 17:229–236.

    PubMed  Article  Google Scholar 

  14. 14.

    Vgontzas AN, Chrousos GP: Sleep, the hypothalamicpituitary-adrenal axis, and cytokines: multiple interactions and disturbances in sleep disorders. Endocrinol Metab Clin North Am 2002, 31:15–36.

    PubMed  Article  CAS  Google Scholar 

  15. 15.

    Krystal AD, Edinger JD, Wohlgemuth WK, Marsh GR: NREM sleep EEG frequency spectral correlates of sleep complaints in primary insomnia subtypes. Sleep 2002, 25:630–640.

    PubMed  Google Scholar 

  16. 16.

    Mellman TA, Hipolito MM: Sleep disturbances in the aftermath of trauma and posttraumatic stress disorder. CNS Spectr 2006, 11:611–615.

    PubMed  Google Scholar 

  17. 17.

    Turner SM, Beidel DC, Frueh BC: Multicomponent behavioral treatment for chronic combat-related posttraumatic stress disorder: trauma management therapy. Behav Modif 2005, 29:39–69.

    PubMed  Article  Google Scholar 

  18. 18.

    Foa EB: Psychosocial treatment of posttraumatic stress disorder. J Clin Psychiatry 2000, 61:43–48.

    PubMed  Google Scholar 

  19. 19.

    Foa EB, Rothbaum BO, Furr JM: Is the efficacy of exposure therapy for PTSD augmented with the addition of other CBT procedures? Psychiatr Ann 2003, 33:47–53.

    Google Scholar 

  20. 20.

    Nickell PV, Uhde TW: Dose-response effects of intravenous caffeine in normal volunteers. Anxiety 1994–1995, 1:161–168.

    PubMed  Google Scholar 

  21. 21.

    Hinton DE, Pich V, Chhean D, et al.: Olfactory-triggered panic attacks among Cambodian refugees attending a psychiatric clinic. Gen Hosp Psychiatry 2004, 26:390–397.

    PubMed  Article  Google Scholar 

  22. 22.

    Vasterling JJ, Brailey K, Sutker PB: Olfactory identification in combat-related posttraumatic stress disorder. J Trauma Stress 2000, 13:241–253.

    PubMed  Article  CAS  Google Scholar 

  23. 23.

    Vermetten E, Bremner JD: Olfaction as a traumatic reminder in posttraumatic stress disorder: case reports and review. J Clin Psychiatry 2003, 64:202–207.

    PubMed  Article  Google Scholar 

  24. 24.

    Kline NA, Rausch JL: Olfactory precipitants of flashbacks in posttraumatic stress disorder: case reports. J Clin Psychiatry 1985, 46:383–384.

    PubMed  CAS  Google Scholar 

  25. 25.

    Mellman TA, Uhde TW: Sleep panic attacks: new clinical findings and theoretical implications. Am J Psychiatry 1989, 146:1204–1207.

    PubMed  CAS  Google Scholar 

  26. 26.

    Uhde TW: The Anxiety Disorders. Principles and Practice in Sleep Medicine, edn 3. Edited by Kryger MH, Roth T, Dement W. Philadelphia: W. B. Saunders; 2000.

    Google Scholar 

  27. 27.

    Uhde T, Merritt-Davis O, Yaroslavsky Y, et al.: Sleep paralysis: overlooked fearful arousal [abstract 96D]. Proceedings of the 159th Annual Meeting of the American Psychiatric Association. Washington, DC: American Psychiatric Association; 2006:250–251.

    Google Scholar 

  28. 28.

    Stein D, Hollander E: The Textbook of Anxiety Disorders, edn 2. Washington, DC: American Psychiatric Press; 2009.

    Google Scholar 

  29. 29.

    Kryger MH, Roth T, Dement WC: Principles and Practice of Sleep Medicine. Philadelphia: W. B. Saunders; 2005.

    Google Scholar 

  30. 30.

    Singareddy R, Uhde TW: Nocturnal sleep panic and depression: relationship to subjective sleep in panic disorder. J Affect Disord 2009, 112:262–266.

    PubMed  Article  Google Scholar 

  31. 31.

    Landry P, Marchand L, Mainguy N, et al.: Electroencephalography during sleep of patients with nocturnal panic disorder. J Nerv Ment Dis 2002, 190:559–562.

    PubMed  Article  Google Scholar 

  32. 32.

    Carskadon MA, Dement WC, Mitler MM, et al.: Self-reports versus sleep laboratory findings in 122 drug-free subjects with complaints of chronic insomnia. Am J Psychiatry 1976, 133:1382–1388.

    PubMed  CAS  Google Scholar 

  33. 33.

    Lydiard RB, Zealberg J, Laraia MT, et al.: Electroencephalography during sleep of patients with panic disorder. J Neuropsychiatry Clin Neurosci 1989, 1:372–376.

    PubMed  CAS  Google Scholar 

  34. 34.

    Sloan EP, Natarajan M, Baker B, et al.: Nocturnal and daytime panic attacks—comparison of sleep architecture, heart rate variability, and response to sodium lactate challenge. Biol Psychiatry 1999, 45:1313–1320.

    PubMed  Article  CAS  Google Scholar 

  35. 35.

    Perlis ML, Kehr EL, Smith MT, et al.: Temporal and stagewise distribution of high frequency EEG activity in patients with primary and secondary insomnia and in good sleeper controls. J Sleep Res 2001, 10:93–104.

    PubMed  Article  CAS  Google Scholar 

  36. 36.

    Thompson CE, Taylor FB, McFall ME, et al.: Nonnightmare distressed awakenings in veterans with posttraumatic stress disorder: response to prazosin. J Trauma Stress 2008, 21:417–420.

    PubMed  Article  Google Scholar 

  37. 37.

    Brown TM, Uhde TW: Sleep panic attacks: a micro-movement analysis. Depress Anxiety 2003, 18:214–220.

    PubMed  Article  Google Scholar 

  38. 38.

    Craske MG, Lang AJ, Aikins D, Mystkowski J: Cognitive behavioral therapy for nocturnal panic. Behav Ther 2005, 36:43–54.

    Article  Google Scholar 

  39. 39.

    Singareddy R, Uhde TW, Commissaris R: Differential effects of hypocretins on noise alone versus potentiated startle responses. Physiol Behav 2006, 89:650–655.

    PubMed  Article  CAS  Google Scholar 

  40. 40.

    Edinger, JD, Krystal AD: Subtyping primary insomnia: is sleep state misperception a distinct clinical entity? Sleep Med Rev 2003, 7:203–214.

    PubMed  Article  Google Scholar 

  41. 41.

    Cantero JL, Atienza M, Salas RM: Spectral features of EEG alpha activity in human REM sleep: two variants with different functional roles? Sleep 2000, 23:746–750.

    PubMed  CAS  Google Scholar 

  42. 42.

    Perlis ML, Giles DE, Mendelson WB, et al.: Psychophysiological insomnia: the behavioural model and a neurocognitive perspective. J Sleep Res 1997, 6:179–188.

    PubMed  Article  CAS  Google Scholar 

  43. 43.

    Buysse DJ, Germain A, Hall ML, et al.: EEG spectral analysis in primary insomnia: NREM period effects and sex differences. Sleep 2008, 31:1673–1682.

    PubMed  Google Scholar 

  44. 44.

    Altena E, Van Der Werf YD, Sanz-Arigita EJ, et al.: Prefrontal hypoactivation and recovery in insomnia. Sleep 2008, 31:1271–1276.

    PubMed  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Thomas W. Uhde.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Uhde, T.W., Cortese, B.M. & Vedeniapin, A. Anxiety and sleep problems: Emerging concepts and theoretical treatment implications. Curr Psychiatry Rep 11, 269–276 (2009). https://doi.org/10.1007/s11920-009-0039-4

Download citation

Keywords

  • Anxiety Disorder
  • Generalize Anxiety Disorder
  • Sleep Problem
  • Social Anxiety Disorder
  • Panic Disorder