Anxiety Disorders and Accompanying Insomnia

Part of the Series in Anxiety and Related Disorders book series (SARD)


In this chapter, we discuss the different manifestations (both subjective and objective) of sleep disturbance within anxiety disorders. We discuss the associated features of the anxiety disorder and focus especially on those anxiety conditions presumed to have higher comorbidity with insomnia. We also consider whether there are any disorder-specific special insomnia treatment considerations within each diagnostic category. We argue that there appears to be no real impediment to treating the insomnia of those with anxiety disorders, although there may be some special treatment considerations for panic disorder (i.e., allowing for a less conservative time-in-bed restriction) and PTSD (i.e., addressing nightmares). We review the 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, and the evidence for a combined approach (i.e., treating the insomnia and anxiety problem concurrently).


Anxiety Disorder Generalize Anxiety Disorder American Psychiatric Association Social Phobia Panic Disorder 


  1. 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.Google Scholar
  2. 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.Google Scholar
  3. 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.PubMedGoogle Scholar
  4. 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.Google Scholar
  5. 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.CrossRefPubMedGoogle Scholar
  6. Belanger, L., Morin, C. M., Langlois, F., ‖ Ladouceur, R. (2004). Insomnia and generalized anxiety disorder: Effects of cognitive behavior therapy for GAD on insomnia symptoms. Journal of Anxiety Disorders, 18, 561–571.CrossRefPubMedGoogle Scholar
  7. Borkovec, T. D. (1982). Insomnia. Journal of Consulting and Clinical Psychology, 50, 880–895.CrossRefPubMedGoogle Scholar
  8. 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.CrossRefPubMedGoogle Scholar
  9. Brown, T., Black, B., ‖ Uhde, T. (1994). The sleep architecture of social phobia. Biological Psychiatry, 35(6), 420–421.CrossRefPubMedGoogle Scholar
  10. Brown, T. M., ‖ Uhde, T. W. (2003). Sleep panic attacks: a micro-movement analysis. Depression and Anxiety, 18, 214–220.CrossRefPubMedGoogle Scholar
  11. 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.PubMedGoogle Scholar
  12. 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.CrossRefPubMedGoogle Scholar
  13. 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.CrossRefGoogle Scholar
  14. Calhoun, P., Bosworth, H., Grambow, S., Dudley, T., ‖ Beckham, J. (2002). Medical service utilization by veterans seeking help for posttraumatic stress disorder. American Journal of Psychiatry, 159, 2081–2086.CrossRefPubMedGoogle Scholar
  15. Cameron, O. G., ‖ Thyer, B. A. (1985). Treatment of pavor nocturnus with alprazolam. Journnal of Clinical Psychology, 46, 405.Google Scholar
  16. 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.CrossRefGoogle Scholar
  17. Craske, M. G., ‖ Barlow, D. H. (1989). Nocturnal panic. Journal of Nervous and Mental Disease, 177, 160–167.CrossRefPubMedGoogle Scholar
  18. Craske, M. G., Lang, A. J., Aikins, D., ‖ Mystkowski, J. L. (2005). Behavior Therapy, 36, 43–54.CrossRefGoogle Scholar
  19. 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.CrossRefPubMedGoogle Scholar
  20. Craske, M. G., Lang, A. J., ‖ Rowe, M. (2002). Pre-sleep attributions about arousal during sleep. Journal of Abnormal Psychology, 111, 53–62.CrossRefPubMedGoogle Scholar
  21. 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.CrossRefPubMedGoogle Scholar
  22. Culpepper, L. (2002). Generalized anxiety disorder in primary care: emerging issues in management and treatment. The Journal of Clinical Psychiatry, 63(Suppl. 8), 35–42.PubMedGoogle Scholar
  23. 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.CrossRefPubMedGoogle Scholar
  24. Dow, B. M., Kelsoe, J., ‖ Gillin, J. (1996). Sleep and dreams in Vietnam PTSD and depression. Biological Psychiatry, 39, 42–50.CrossRefPubMedGoogle Scholar
  25. 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.PubMedGoogle Scholar
  26. Edinger, J. D., ‖ Radtke, R. A. (1993). Use of in vivo desensitization to treat a patient’s claustrophobic response to nasal CPAP. Sleep, 16(7), 678–680.PubMedGoogle Scholar
  27. 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.CrossRefPubMedGoogle Scholar
  28. 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.CrossRefPubMedGoogle Scholar
  29. Fireman, B., Koran, L., Leventhal, J., ‖ Jacobson, A. (2001). The prevalence of clinically recognized obsessive-compulsive disorder in a large health maintenance organization. American Journal of Psychiatry, 158(11), 1904–1910.CrossRefPubMedGoogle Scholar
  30. 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.PubMedGoogle Scholar
  31. 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.CrossRefPubMedGoogle Scholar
  32. Fuller, K. H., Waters, W. F., Binks, P. G., ‖ Anderson, T. (1997). Generalized anxiety and sleep architecture: a polysomnographic investigation. Sleep, 20, 370–376.PubMedGoogle Scholar
  33. Grant, B., Hasin, D., Blanco, C., Stinson, F., Chou, S., Goldstein, R., et al. (2005). The epidemiology 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.CrossRefPubMedGoogle Scholar
  34. Grillon, C., Pellowski, M., Merikangas, K. R., ‖ Davis, M. (1997). Darkness facilitates the acoustic startle reflex in humans. Biological Psychiatry, 42(6), 453–460.CrossRefPubMedGoogle Scholar
  35. Gross, R., ‖ Borkovec, T. (1982). Effects of cognitive intrusion manipulation on the sleep onset latency of good sleepers. Behaviour Therapy, 13, 112–116.CrossRefGoogle Scholar
  36. Hantouche, E., Bouhassira, M., Lancrenon, S., Ravily, V., ‖ Bourgeois, M. (1995). Prevalence of obsessive-compulsive disorders in a large French patient population in psychiatric consultation. Encephale, 21(5), 571–580.PubMedGoogle Scholar
  37. Harvey, A. G., ‖ Greenall, E. (2003). Catastrophic worry in primary insomnia. Journal of Behavior Therapy Experimental Psychiatry, 34(1), 11–23.CrossRefGoogle Scholar
  38. 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.CrossRefPubMedGoogle Scholar
  39. 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.CrossRefPubMedGoogle Scholar
  40. 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.CrossRefPubMedGoogle Scholar
  41. 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.PubMedGoogle Scholar
  42. Kamath, P., Reddy, Y. C., ‖ Kandavel, T. (2007). Suicidal behavior in obsessive-compulsive disorder. Journal of Clinical Psychiatry, 68(11), 1741–1750.CrossRefPubMedGoogle Scholar
  43. 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.PubMedGoogle Scholar
  44. 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.CrossRefPubMedGoogle Scholar
  45. 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.CrossRefPubMedGoogle Scholar
  46. 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.CrossRefGoogle Scholar
  47. Kobayashi, I., Boarts, J. M., ‖ Delahanty, D. L. (2007). Polysomnographically measured sleep abnormalities in PTSD: A meta-analytic review. Psychophysiology, 44(4), 660–669.CrossRefPubMedGoogle Scholar
  48. Krakow, B., Hollifield, M., Schrader, R., Koss, M., Tandberg, D., ‖ Lauriello, J. (2000). A controlled study of imargery rehearsal for chronic nightmares in sexual assault survivors with PTSD: a preliminary report. Journal of Traumatic Stress, 13(4), 589–609.CrossRefPubMedGoogle Scholar
  49. Krakow, B., Johnston, L., Melendrez, D., Hollifield, M., Warner, T. D., Chavez-Kennedy, D., et al. (2001). An open-label trial of evidence-based cognitive behavior therapy for nightmares and insomnia in crime victims with PTSD. American Journal of Psychiatry, 158(12), 2043–2047.CrossRefPubMedGoogle Scholar
  50. Kuch, K., ‖ Cox, B. (1992). Symptoms of PTSD in 124 survivors of the Holocaust. American Journal of Psychiatry, 149(3), 337–340.PubMedGoogle Scholar
  51. Lavie, P., ‖ Hertz, G. (1979). Increased sleep motility and respiration rates in combat neurotic patients. Biological Psychiatry, 14, 983–987.PubMedGoogle Scholar
  52. Lavie, P., Katz, N., Pillar, G., ‖ Zinger, Y. (1998). Elevated awakening thresholds during sleep: characteristics of chronic war-related posttraumatic stress disorder patients. Biological Psychiatry, 44, 1060–1065.CrossRefPubMedGoogle Scholar
  53. Lineberger, M., Carney, C., Edinger, J., ‖ Means, M. (2006). Defining Insomnia: Quantitative criteria for insomnia severity and frequency. Sleep, 29, 479–485.PubMedGoogle Scholar
  54. Means, M. K., ‖ Edinger, J. D. (2007). Graded exposure therapy for addressing claustrophobic reactions to continuous positive airway pressure: a case series report. Behavioral Sleep Medicine, 5(2), 105–116.PubMedGoogle Scholar
  55. Mellman, T., Kulick-Bell, R., Ashlock, L., ‖ Nolan, B. (1995). Sleep events among veteran with posttraumatic stress disorder. American Journal of Psychiatry, 152, 110–115.PubMedGoogle Scholar
  56. Mellman, T., Nolan, B., Hebding, J., ‖ Kulick-Bell, R. (1997). A polysomnographic comparison of veterans with combat-related PTSD, depressed mean and non-ill controls. Sleep, 20, 46–51.PubMedGoogle Scholar
  57. Mellman, T. A., Kuman, A., Kulick-Bell, R., Kuman, M., ‖ Nolan, B. (1995). Nocturnal/daytime urine noradrenergic measures and sleep in combat-related PTSD. Biological Psychiatry, 38, 174–179.CrossRefPubMedGoogle Scholar
  58. Mellman, T. A., ‖ Uhde, T. W. (1989). Sleep panic attacks: New clinical findings and theoretical implications. American Journal of Psychiatry, 146, 1024–1027.Google Scholar
  59. Mellman, T. A., ‖ Uhde, T. W. (1990). Patients with frequent sleep panic: Clinical findings and response to medication treatment. Journal of Clinical Psychiatry, 51(12), 513–516.PubMedGoogle Scholar
  60. Monti, J. M., ‖ Monti, D. (2000). Sleep disturbance in generalized anxiety disorder and its treatment. Sleep Medicine Reviews, 4(3), 263–276.CrossRefPubMedGoogle Scholar
  61. Morin, C., Bootzin, R., Buysse, D., Edinger, J., Espie, C., ‖ Lichstein, K. (2006). Psychological and behavioral treatment of insomnia: update of the recent evidence (1998–2004). Sleep, 29(11), 1398–1414.PubMedGoogle Scholar
  62. Neylan, T., Marmar, C., Metzler, T., Weiss, D., Zatzick, D., ‖ Delucchi, K. (1998). Sleep disturbances in the Vietnam generation: Findings from a nationally representative sample of male Vietnam Veterans. American Journal of Psychiatry, 155, 929–933.PubMedGoogle Scholar
  63. Papadimitriou, G., ‖ Linkowski, P. (2005). Sleep disturbance in anxiety disorders. International Review of Psychiatry, 17(4), 229–236.CrossRefPubMedGoogle Scholar
  64. Papadimitriou, G. N., Kerkhofs, M., Kempenaers, C., ‖ Mendlewicz, J. (1988). EEG sleep studies in patients with generalized anxiety disorder. Psychiatry Research, 26, 183–190.CrossRefPubMedGoogle Scholar
  65. Pillar, G., Harder, L., ‖ Malhotra, A. (2006). Trauma and post-traumatic stress disorder. In T. Lee-Chiong (Ed.), Sleep: A comprehensive handbook (pp. 857–866). Hoboken, NJ: John Wiley ‖ Sons.Google Scholar
  66. Pollack, M. H., Kinrys, G., Krystal, A. D., McCall, V. W., Roth, T., Schaefer, K., et al. (2008). Eszopiclone coadministered with escitalopram in patients with insomnia and comorbid generalized anxiety disorder. Archives of General Psychiatry, 65(5), 551–562.CrossRefPubMedGoogle Scholar
  67. Reynolds, C. F., III, Shaw, D. H., Newton, T. F., Coble, P. A., ‖ Kupfer, D. J. (1983). EEG sleep in outpatients with generalized anxiety: a preliminary comparison with depressed outpatients. Psychiatry Research, 8, 81–89.CrossRefPubMedGoogle Scholar
  68. Robinson, D., Walsleben, J., Pollack, S., ‖ Lerner, G. (1998). Nocturnal polysomnography in obsessive-compulsive disorder. Psychiatry Reseach, 80(3), 257–263.CrossRefGoogle Scholar
  69. Rosa, R. R., Bonnet, M. H., ‖ Kramer, M. (1983). The relationship of sleep and anxiety in anxious subjects. Biological Psychology, 16, 119–126.CrossRefPubMedGoogle Scholar
  70. Ross, R., Ball, W., Sullivan, K., ‖ Caroff, S. (1989). Sleep disturbance as a hallmark of posttraumatic stress disorder. American Journal of Psychiatry, 146, 697–707.PubMedGoogle Scholar
  71. Roy-Byrne, P. P., Uhde, T. W., ‖ Post, R. M. (1986). Effects of one night’s sleep deprivation on mood and behavior in panic disorder: Patients with panic disorder compared with depressed patients and normal controls. Archives of General Psychiatry, 43(9), 895–899.PubMedGoogle Scholar
  72. Smith, M. T., Huang, M. I., ‖ Manber, R. (2005). Cognitive Behavior Therapy for chronic insomnia occuring within the context of medical and psychiatric disorders. Clinical Psychology Review, 25, 559–592.CrossRefPubMedGoogle Scholar
  73. Stein, M., Kroft, C., ‖ Walker, J. (1993). Sleep impairment in patients with social phobia. Psychiatry Research, 49(3), 251–256.CrossRefPubMedGoogle Scholar
  74. Stein, M., ‖ Mellman, T. (2005). Anxiety Disorders. In M. Kyrger, T. Roth, ‖ W. Dement (Eds.), Principles and practice of sleep medicine (4th ed., pp. 1297–1310). Philadelphia: Elsevier Saunders.Google Scholar
  75. Stein, M. B., Enns, M. W., ‖ Kryger, M. H. (1993). Sleep in nondepressed patients with panic disorder II: Polysomnographic assessment of sleep architecture and sleep continuity. Journal of Affective Disorders, 28, 1–6.CrossRefPubMedGoogle Scholar
  76. Stengler-Wenzke, K., Krolla, M., Matschingera, H., ‖ Angermeyera, M. C. (2006). Quality of life of relatives of patients with obsessive-compulsive disorder. Comprehensive Psychiatry, 47(6), 523–527.CrossRefPubMedGoogle Scholar
  77. Thase, M. E., Rush, A. J., Manber, R., Kornstein, S. G., Klein, D., ‖ Markowitz, J. C. (2002). Effects of nefazodone and cognitive behavioral analysis system of psychotherapy, singly and in combination, on insomnia associated with chronic depression. Journal of Clinical Psychiatry, 63(6), 493–500.PubMedGoogle Scholar
  78. Todaro, J., Shen, B., Raffa, S., Tilkemeier, P., ‖ Niaura, R. (2007). Prevalence of anxiety disorders in men and women with established coronary heart disease. Journal of Cardiopulmonary Rehabilitation and Prevention, 27(2), 86–91.PubMedGoogle Scholar
  79. Torres, A. R., Prince, M. J., Bebbington, P. E., Bhugra, D., Brugha, T. S., Farrell, M., et al. (2006). Obsessive-compulsive disorder: Prevalence, comorbidity, impact, and help-seeking in the British National Psychiatric Morbidity Survey of 2000. The American Journal of Psychiatry, 163, 1978–1985.CrossRefPubMedGoogle Scholar
  80. Tukel, R., Meteris, H., Koyuncu, A., Tecer, A., ‖ Yazici, O. (2006). The clinical impact of mood disorder comorbidity on obsessive-compulsive disorder. European Archives of Psychiatry and Clinical Neuroscience, 256, 240–245.CrossRefPubMedGoogle Scholar
  81. Voderholzer, U., Riemann, D., Huwig-Poppe, C., Kuelz, A., Kordon, A., Bruestle, K., et al. (2007). Sleep in obsessive compulsive disorder: polysomnographic studies under baseline conditions and after experimentally induced serotonin deficiency. European Archives of Psychiatry and Clinical Neuroscience, 257(3), 173–182.CrossRefPubMedGoogle Scholar
  82. Walker, E. A., Katon, W., Russo, J., Ciechanowski, P., Newman, E., ‖ Wagner, A. (2003). Health care costs associated with Posttraumatic Stress Disorder symptoms in women. Archives of General Psychiatry, 60, 369–374.CrossRefPubMedGoogle Scholar
  83. Weissberg, M. (2006). Anxiety disorders and sleep. In T. Lee-Chiong (Ed.), Sleep: A comprehensive handbook (pp. 845–855). Hoboken, NJ: John Wiley ‖ Sons.Google Scholar
  84. Woodward, S., Friedman, M., ‖ Bliwise, D. (1996). Sleep and depression in combat-related PTSD inpatients. Biological Psychiatry, 39, 182–192.CrossRefPubMedGoogle Scholar
  85. Woodward, S., Murburg, M., ‖ Bliwise, D. (2000). PTSD-related hyperarousal assessed during sleep. Physiology and Behavior, 70(1–2), 197–203.CrossRefPubMedGoogle Scholar
  86. Zayfert, C., ‖ DeViva, J. C. (2004). Residual insomnia following cognitive behavioral therapy for PTSD. Journal of Traumatic Stress, 17(1), 69–73.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Department of PsychologyRyerson UniversityTorontoCanada
  2. 2.Department of Psychiatry and Behavioral SciencesDuke University Medical CenterDurhamUSA

Personalised recommendations