Other Issues in Managing the Sleep of Those with Anxiety

  • Colleen E. Carney
  • Jack D. Edinger
Part of the Series in Anxiety and Related Disorders book series (SARD)


We have presented the core treatment strategies of CBT for insomnia in the previous chapters, but there are potential challenges unique to those suffering from comorbid anxiety problems that should be discussed. Herein, we present specific instructions/protocols for managing sleep problems in the context of anxiety and anxiety disorders, including relaxation-based strategies (focusing specifically on Progressive Muscle Relaxation), Cognitive Behavioral Treatment of Nocturnal Panic (Craske et al., Behavior Therapy 36:43-54, 2005), treating claustrophobia for those using CPAP for sleep apnea, and dream/nightmare rescripting. While a major goal of this text is that of providing practitioners guidance in the use of psychological strategies for the management of sleep problems with anxiety as a prominent feature, the problems discussed may represent only a subset of the varied forms of sleep disturbances that may present as primary or comorbid sleep disorders. Many people with such conditions require and benefit from one or more consultations with a sleep specialist. Hence, we provide discussion and a resource for use in determining whether the type of sleep problem and circumstances warrant a sleep specialty referral.


Sleep Apnea Anxiety Disorder Progressive Muscle Relaxation Sleep Specialist Relaxation Therapy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Aloia, M., Arnedt, J., Riggs, R., Hecht, J., & Borrelli, B. (2004). Clinical management of poor adherence to CPAP: Motivational enhancement. Behavioral Sleep Medicine, 2, 205–222.CrossRefPubMedGoogle Scholar
  2. Beecroft, J., Zanon, S., Lukic, D., & Hanly, P. (2003). Oral continuous positive airway pressure for sleep apnea: Effectiveness, patient preference, and adherence. Chest, 124, 2200–2208.CrossRefPubMedGoogle Scholar
  3. Benson, H. (1984). Beyond the relaxation response: How to harness the healing power of your personal beliefs. New York: Berkley Books.Google Scholar
  4. Bernstein, D., & Borkovec, T. D. (1973). Progressive relaxation training. Champaign, Ill: Research Press.Google Scholar
  5. Berquier, A., & Ashton, R. (1992). Characteristics of the frequent nightmare sufferer. Journal of Abnormal Psychology, 101, 246–250.CrossRefPubMedGoogle Scholar
  6. Bishay, N. (1985). Therapeutic manipulation of nightmares and the management of neuroses. British Journal of Psychaitry, 147, 67–70.CrossRefGoogle Scholar
  7. Bixler, E., Kales, A., & Soldatos, C. (1979). Sleep disorder encountered in medical practice: A national survey. Behavioral Medicine, 6, 13–21.Google Scholar
  8. Borkovec, T. D., & Fowles, D. C. (1973). Controlled investigation of the effects of progressive relaxation and hypnotic relaxation on insomnia. Journal of Abnormal Psychology, 82, 153–158.CrossRefPubMedGoogle Scholar
  9. Brylowski, A. (1990). Nightmares in crisis: Clinical applications of lucid dreaming techniques. Psychiatry Journal of the University of Ottawa, 15, 79–84.Google Scholar
  10. Cartwright, R., Young, M., Mercer, P., & Bears, M. (1998). Role of REM sleep and dream variables in prediction of remission from depression. Psychiatry Research, 80, 249–255.CrossRefPubMedGoogle Scholar
  11. Cellucci, A., & Lawrence, P. (1978). The efficacy of systematic desensitization in reducing nightmares. Journal of Behavior Therapy and Experimental Psychiatry, 9, 109–114.CrossRefGoogle Scholar
  12. Cernovsky, Z. (1985). MMPI and nightmares in male alcoholics. Perceptual and Motor Skills, 61, 841–842.PubMedGoogle Scholar
  13. Cernovsky, Z. (1986). MMPI and nightmares reports in women addicted to alcohol and other drugs. Perceptual and Motor Skills, 62, 717–718.PubMedGoogle Scholar
  14. Chasens, E. R., Pack, A., Maislin, G., Dinges, D., & Weaver, T. (2005). Claustrophobia and adherence to CPAP treatment. Western Journal of Nursing Research, 27, 307–321.CrossRefPubMedGoogle Scholar
  15. Clum, G., Clum, G., & Surls, R. (1993). A meta-analysis of treatments for panic disorder. Journal of Consulting and Clinical Psychology, 61(2), 317–326.CrossRefPubMedGoogle Scholar
  16. Connor, K. M., Davidson, J. R., Churchill, L. E., Sherwood, A., Foa, E. B., & Weisler, R. H. (2000). Psychometric properties of the Social Phobia Inventory (SPIN): A new self-rating scale. British Journal of Psychiatry, 176, 379–386.CrossRefPubMedGoogle Scholar
  17. Craske, M. G., Lang, A. J., Aikins, D., & Mystkowski, J. L. (2005). Cognitive behavioral therapy for nocturnal panic. Behavior Therapy, 36, 43–54.CrossRefGoogle Scholar
  18. Edinger, J., Wohlgemuth, W., Radtke, R., Marsh, G., & Quillian, R. (2001). Cognitive behavioral therapy for treatment of chronic Primary Insomnia: A randomized controlled trial. The Journal of the American Medical Association, 285, 1856–1864.CrossRefGoogle Scholar
  19. 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
  20. Engleman, H., & Wild, M. (2003). Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS). Sleep Medicine Reviews, 7, 81–99.CrossRefPubMedGoogle Scholar
  21. Foa, E., Riggs, D., Dancu, C., & Rothmaum, B. (1993). Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress, 6, 459–473.CrossRefGoogle Scholar
  22. Forbes, D., Creamer, M., & Biddle, D. (2001). The validity of the PTSD checklist as a measurs of symptomatic change in combat-related PTSD. Behaviour Research and Therapy, 39, 977–986.CrossRefPubMedGoogle Scholar
  23. Forbes, D., Phelps, A., McHugh, A., Debenham, P., Hopwood, M., & Creamer, M. (2003). Imagery rehearsal in the treatment of posttraumatic nightmares in Australian Veterans with chronic combat-related PTSD: 12-month follow-up data. Journal of Traumatic Stress, 16(5), 509–513.CrossRefPubMedGoogle Scholar
  24. 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
  25. Futterman, A., & Shapiro, D. (1986). A review of biofeedback for mental disorders. Hospital and Community Psychiatry, 37(1), 27–33.PubMedGoogle Scholar
  26. Grunstein, R., & Sullivan, C. (2000). Continuous positive airway pressure for slep breathing disorders. In M. Kryger, T. Roth, & W. Dement (Eds.), Principles and practice of sleep medicine (3rd ed., pp. 894–912). Philadelphia: W. B. Saunders Company.Google Scholar
  27. Hartmann, E. (1984). The nightmare: The psychology and biology of terrifying drams. New York: Basic Books.Google Scholar
  28. Jacobson, E. (1964). Anxiety and tension control. Philadelphia: Lippincott.Google Scholar
  29. Jenkins, N., Mrad, R., & Walsh, J. (1991). Long term nasal CPAP use and follow-up care. Sleep Research, 20, 56.Google Scholar
  30. Jorm, A., Christensen, H., Griffiths, K., Parslow, R., Rodgers, B., & Blewitt, K. (2004). Effectiveness of complementary and self-help treatments for anxiety disorders. Medical Journal of Australia, 181(7 suppl.), S29–S46.PubMedGoogle Scholar
  31. Kales, A., Soldatos, C., & Caldwell, A. B. (1980). Nightmares: Clinical characteristics and personality patterns. American Journal of Psychiatry, 137, 1197–1201.PubMedGoogle Scholar
  32. Kilpatrick, D., Resnick, H., Freedy, J., Pelcovitz, D., Resick, P., & Roth, S. (1998). Posttraumatic stress disorder field trial: evaluation of the PTSD construct-criteria A through E. In T. Widiger & A. Frances (Eds.), DSM-IV sourcebook. Washington, DC: American Psychiatric Press.Google Scholar
  33. Koontz, K. L., Slifer, K. J., Cataldo, M. D., & Marcus, C. L. (2003). Improving pediatric compliance with positive airway pressure therapy: The impact of behavioral intervention. Sleep, 26, 1010–1015.PubMedGoogle Scholar
  34. Krakow, B., Hollifield, M., Johnson, L., Koss, M., Schrader, R., Warner, T., et al. (2001). Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: A randomized controlled trial. The Journal of the American Medical Association, 286, 537–545.CrossRefGoogle Scholar
  35. Krakow, B., Hollifield, M., Schrader, R., Koss, M., Tandberg, D., Lauriello, J., et al. (2000). A controlled study of imargery rehearsal for chronic nightmares in sexual assault survirors with PTSD: A preliminary report. Journal of Traumatic Stress, 13(4), 589–609.CrossRefPubMedGoogle Scholar
  36. Krakow, B., Johnston, L., Melendrez, D., Hollifield, M., Warner, T., 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
  37. Krakow, B., Kellner, R., Pathak, D., & Lambert, L. (1995). Imagery rehearsal treatment for chronic nightmares. Behaviour Research and Therapy, 33(7), 837–843.CrossRefPubMedGoogle Scholar
  38. Krakow, B., Sandoval, D., Schrader, R., Keuhne, B., McBride, L., Yau, C., et al. (2001). Treatment of chronic nightmares in adjudicated adolescent girls in a residential facility. Journal of Adolescent Health, 29, 94–100.CrossRefPubMedGoogle Scholar
  39. Krakow, B., Schrader, R., Tandberg, D., Hollifield, M., Koss, M., & Yau, C. (2002). Nightmare frequency in sexual assault survivors with PTSD. Journal of Anxiety Disorders, 16, 175–190.CrossRefPubMedGoogle Scholar
  40. Krakow, B., Tandberg, D., Scriggins, L., & Barey, M. (1995). A controlled comparison of self-rated sleep complaints in aute and chronic nightmare sufferers. Journal of Nervous and Mental Disease, 183, 623–627.CrossRefPubMedGoogle Scholar
  41. Krakow, B., & Zadra, A. (2006). Clinical management of chronic nightmares: Imagery rehearsal therapy. Behavioral Sleep Medicine, 4(1), 45–70.CrossRefPubMedGoogle Scholar
  42. Kribbs, N., Pack, A., Kline, L., Smith, P., Schwartz, A., & Schubert, N. (1993). Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. American Review of Respiratory Disease, 147, 887–895.PubMedGoogle Scholar
  43. Lansky, M. (1995). Post truamatic nightmares: Psycho-dynamic explorations. Hillsdale, NJ: The Analytic Press.Google Scholar
  44. Levin, R. (1998). Nightmares and schizotypy. Psychiatry and Clinical Neurosciences, 61, 206–216.Google Scholar
  45. Lichstein, K. L. (1988). Clinical relaxation strategies. Hoboken, NJ: John Wiley and Sons Ltd.Google Scholar
  46. Littner, M., Hirshkowitz, M., Kramer, M., Kapen, S., Anderson, W., & Bailey, D. (2003). Practice parameters for using polysomnography to evaluate insomnia: An update. Sleep, 26(6), 754–760.PubMedGoogle Scholar
  47. Mack, J. (1974). Nightmares and human conflict. Boston: Houghton Mifflin.Google Scholar
  48. Marks, I. (1978). Rehearsal relief of a nightmare. British Journal of Psychiatry, 135, 461–465.CrossRefGoogle Scholar
  49. Means, M. (2002). Mind over matter: Optimizing CPAP compliance. Advance for Managers of Respiratory Care, 11, 10–13.Google Scholar
  50. Means, M., & Edinger, J. (2007). Graded exposure therapy for addressing claustrophobic reactions to continuous positive airway pressure: A case series report. Behavioral Sleep Medicine, 5, 105–116.PubMedGoogle Scholar
  51. 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.Google Scholar
  52. Miller, W., & DiPilato, M. (1983). Treatment of nightmares via relaxation and desensitization: A controlled evaluation. Journal of Consulting and Clinical Psychology, 51, 870–877.CrossRefPubMedGoogle Scholar
  53. Morin, C. M., Culbert, J. P., & Schwartz, S. M. (1994). Nonpharmacological interventions for insomnia: A meta-analysis of treatment efficacy. American Journal of Psychiatry, 151, 1172–1180.PubMedGoogle Scholar
  54. Murtagh, D. R., & Greenwood, K. M. (1995). Identifying effective psychological treatments for insomnia: A meta-analysis. Journal of Consulting and Clinical Psychology, 63, 79–89.CrossRefPubMedGoogle Scholar
  55. Neidhardt, E., Krakow, B., Kellner, R., & Pathak, D. (1992). The beneficial effects of one treatment session and recording of nightmares on chronic nightmare sufferers. Sleep, 15(5), 470–473.PubMedGoogle Scholar
  56. 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
  57. Nicassio, P., & Bootzin, R. R. (1974). A comparison of progressive relaxation and autogenic training as treatments for insomnia. Journal of Abnormal Psychology, 83, 253–260.CrossRefPubMedGoogle Scholar
  58. Nielsen, T., & Zadra, A. (2005). Nightmares and other common dream disturbances. In M. Kryger, T. Roth, & W. Dement (Eds.), Principles and practice of sleep medicine (4th ed.). Philadelphia: Elsevier Saunders.Google Scholar
  59. Norton, P., & Price, E. (2007). A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. Journal of Nervous and Mental Disease, 195(6), 521–531.CrossRefPubMedGoogle Scholar
  60. Nowell, P. D., Mazumdar, S., Buysse, D. J., Dew, M. A., Reynolds, C. F. I., & Kupfer, D. J. (1997). Benzodiazepines and zolpidem for chronic insomnia: A meta-analysis of treatment efficacy. Journal of the American Medical Association, 278, 2170–2177.CrossRefPubMedGoogle Scholar
  61. Partinen, M. (1994). Epidemiology of sleep disorders. In M. Kryger, T. Roth, & W. Dement (Eds.), Principles and practice of sleep medicine (2nd ed.). Philadelphia: WB Saunders.Google Scholar
  62. Rains, J. C. (1995). Treatment of obstructive sleep apnea in pediatric patients: Behavioral intervention for compliance with nasal continuous positive airway pressure. Clinical Pediatrics, 34, 535–541.CrossRefPubMedGoogle Scholar
  63. Rauscher, H., Popp, W., Wanke, T., & Zwick, H. (1991). Acceptance of CPAP therapy for sleep apnea. Chest, 100, 1019–1023.CrossRefPubMedGoogle Scholar
  64. Rolfe, I., Olson, L., & Saunders, N. (1991). Long-term aceptance of continuous positive airway pressure in obstructive sleep apnea. American Review of Respiratory Disease, 144, 1130–1133.PubMedGoogle Scholar
  65. 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. Arch Gen Psychiatry, 43(9), 895–899.PubMedGoogle Scholar
  66. Rybarczyk, B., Stepanski, E., Fogg, L., Lopez, M., Barry, P., & Davis, A. (2005). A placebo-controlled test of Cognitive-Behavioral Therapy for comorbid insomnia in older adults. Journal of Consulting and Clinical Psychology, 73(6), 1164–1174.CrossRefPubMedGoogle Scholar
  67. Sanders, M., Gruendl, C., & Rogers, R. (1986). Patient compliance with nasal CPAP therapy for sleep apnea. Chest, 90, 331–333.Google Scholar
  68. Schreuder, B., van Egmond, M., Kleijn, W., & Visser, A. (1998). Daily reports of posttraumatic nightmares and anxiety dreams in Dutch war victims. Journal of Anxiety Disorders, 12, 511–524.CrossRefPubMedGoogle Scholar
  69. Schultz, J. H., & Luthe, W. (1959). Augenic training. New York: Grune & Stratton.Google Scholar
  70. Siev, J., & Chambless, D. (2007). Specificity of treatment effects: Cognitive therapy and relaxation for generalized anxiety and panic disorders. Journal of Consulting and Clinicial Psychology, 75(4), 513–522.CrossRefGoogle Scholar
  71. Smith, J. (1990). Cognitive-behavioral relaxation training: A new system of strategies for treatment and assessment. New York: Springer Publishing Company.Google Scholar
  72. Stetter, F., & Kupper, S. (2002). Autogenic training: A meta-analysis of clinical outcome studies. Applied Psychophysiology and Biofeedback, 27(1), 45–98.CrossRefPubMedGoogle Scholar
  73. Zadra, A., & Dondri, D. (2000). Nightmares and bad dreams: Their prevalence and relationship to well-being. Journal of Abnormal Psychology, 109, 273–281.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