According to Anxiety and Depression Association of America (ADAA), anxiety is a reaction to stress. Its key markers are feelings of tension, worried thoughts, and physical changes such as elevated blood pressure.
Just like physical pain, in and of itself anxiety is not a bad thing: it signals that something is wrong. Temporary anxiety is normal and can count as healthy, because it draws our attention to causes of stress that might need correcting. But anxiety disorders–the excessive and chronic reactions to stress–are mental illnesses. Anxiety disorders are, in other words, worry that sticks way past its usefulness to us; it does not go away and often gets worse with time. According to National Institute of Mental Health, anxiety disorders–from post-traumatic stress disorder, through obsessive compulsive disorder, to a variety of phobias–are the most common mental disorders experienced by Americans. They affect 40 million adults over 18 in the United States, or 18 percent of the population. Many anxiety disorders negatively affect sleep–and vice versa. Doctors call them comorbid: they go hand-in-hand. In other words, anxiety and sleep are connected via a self-reinforcing feedback loop. Feeling rested has been proved to combat anxiety and feeling less anxious leads to sounder sleep. The converse is also true: insomnia feeds anxiety and anxiety keeps us up at night. According to The Cleveland Clinic, two-thirds of patients referred to sleep disorders centers have a psychiatric disorder. “Anxiety is an emotion that actually wakes us up,” Dr. Steve Orma, author of Stop Worrying and Go to Sleep: How to Put Insomnia to Bed for Good, told The Huffington Post. “There are all kinds of physical changes happening that ramp you up, which is the exact opposite state of what you need to be in when you’re trying to fall asleep.”
This guide gets at the link between anxiety and sleep and covers several anxiety disorders that interfere with sleep and which can be alleviated with sleep: generalized anxiety disorder (GAD); social anxiety; obsessive-compulsive disorder (OCD); phobias; post-traumatic stress disorder (PTSD); and panic disorder. It offers solutions to the sleep deprived anxiety sufferers, from treatment options, through online forums, tips regarding healthy sleep hygiene and banishing anxious thoughts, to medical associations that can help.
Anxiety and lack of sleep
Anyone who lost a night to insomnia on account of troubling thoughts has been where many chronic anxiety sufferers find themselves all too frequently. According to UC Berkeley researchers, lack of sleep plays a role in ramping up brain regions that trigger excessive worry. Additionally, those who tend to worry too much are more vulnerable to sleep disorders. “These findings help us realize that those people who are anxious by nature are the same people who will suffer the greatest harm from sleep deprivation,” said Matthew Walker, a professor of psychology and neuroscience at UC Berkeley and senior author of the study. Worry about lack of sleep becomes a self-fulfilling prophecy at times. Anxiety causes sleep loss, which in turn can provoke further anxiety in sufferers. The mechanism behind this phenomenon has to do with what researchers call anticipatory anxiety. People prone to sleep deprivation worry that they might not be able to sleep, perhaps based on past experience. That worry fires up the brain’s amygdala and insular cortex, mimicking the neural activity seen in anxiety disorders. And now, indeed, because of the anticipatory anxiety, sleep becomes elusive. Researchers at University of California Berkeley’s Sleep and Neuroimaging Laboratory found that when deprived of sleep, the brain reverts back to more primitive patterns of activity. What this means is that subjects kept awake were less likely to put emotionally-charged information in context. The good news is found in the reverse. Doing the opposite–finding ways to get better sleep–presents us with a tried-and-true solution to alleviate anxiety. “By restoring good quality sleep in people suffering from anxiety, we may be able to help ameliorate their excessive worry and disabling fearful expectations,” says Dr. Allison Harvey, one of the authors of the study published in the Journal of Neuroscience.
Generalized Anxiety Disorder
People living with generalized anxiety disorder (GAD), also known as free-floating anxiety, are prone to an exaggerated sense of worry regarding everyday events. The worry tends to persist no matter the circumstances. According to DSM-5, which is short for the fifth and the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, if the excessive anxiety and worry about events or activities goes on for most days of the week for at least six months, it points to GAD.
Persistent obsession that is disproportionate to the concerns and the potential consequences of the object of worry
Inability to set the worry aside and relax
Difficulty maintaining focus and concentration
Frequent decision-making paralysis
Worrying about worst-case scenarios
The persistent chatter of generalized anxiety is a voice that’s difficult to quiet at bedtime. Fifty percent of patients diagnosed with generalized anxiety disorder have sleep disorders. Difficulty falling and staying asleep as well as walking up to panic attacks (sudden awakenings to intense anxiety, heart palpitations, shortness of breath, sweating or chills, and often the irrational fear of impending death) are common effects of GAD on sleep.
Determining that a patient has generalized anxiety disorder can be tricky because it often mimics and coexists with mental health illnesses such as phobias, depression, and PTSD. The persistence of excessive worry and the inability to control it for most days during the period of six months is a key marker of the GAD diagnosis. The absence of a particular trigger or trauma is also a distinguishing marker. For more features used by doctors to diagnose GAD, the questionnaire provided by the ADAA can be of help.
Getting better rest at night can do wonders for the symptoms of free-floating anxiety. Sleep researchers at Harvard have found that consolidated slumber throughout a whole night, in all its stages, helps people learn and make memories while impaired sleep reduces the ability to focus and acquire new information.
In turn, treating the symptoms of GAD can lead to better sleep because an effective treatment diminishes restlessness and helps gain control of worry.
The two common ways of treating GAD’s symptoms are psychotherapy and drugs. They are often used in conjunction. Both have the power to alter brain chemistry.
Psychotherapy, such as cognitive behavioral therapy or mindfulness therapy, helps patients learn skills (such as distraction, detachment from negative thoughts, cognitive restructuring, exposure therapy) with which they can learn to abort obsessive worry.
Antidepressants (particularly SSRIs) can help, over time, to influence the activity of neurotransmitters in the brain—serotonin, dopamine, and norepinephrine–by increasing their presence. These neurotransmitters are responsible for maintaining mood balance and helping people put concerns in context. It takes a few weeks of well-tuned and consistent use for antidepressants to render effective results. Tranquilizers known as benzodiazepines–for example, Xanax and Ativan–can in the meantime be used occasionally to prevent acute attacks of anxiety, such as panic attacks.
Some studies have found that, depending on the individual, talk therapy can be as effective as antidepressants.
The Mayo Clinic discusses treatments available for generalized anxiety
ADAA offers ways to treat anxiety and depression, which often coexist
DSM-5 defines social anxiety disorder as a “persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others.”
The socially anxious person fears acting in a way that might be embarrassing or humiliating. The fear of judgment by others often leads to avoidance of social situations or attacks of anxiety in social contexts, interfering with the socially anxious person’s normal routine, relationships, and professional goals for the period of at least six months. Fifteen million American adults live with social anxiety disorder.
A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others
Exposure to the feared situation almost invariably provokes anxiety (which can manifest in panic attacks)
The sufferer recognizes that this fear is unreasonable or excessive
The feared situations are avoided or else are endured with intense anxiety and distress
The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine and functioning
The fear, anxiety, or avoidance is persistent, typically lasting 6 or more months
Because a good night’s rest is proven to stabilize people’s moods and emotional regulation, it is important for social anxiety sufferers to get enough sleep. Not enough sleep boosts anticipatory anxiety, which troubles the socially anxious in the lead-up to social situations, often preventing their ability to sleep at night. According to UC Berkeley researchers, “By restoring good quality sleep in people suffering from anxiety, we may be able to help ameliorate their excessive worry and disabling fearful expectations.”
To be diagnosed with the disorder, persons must have persistent fear, anxiety, or avoidance that last for six months and interfere with their usual routine, occupational tasks, and relationships.
When diagnosing a patient, doctors sometimes confuse social anxiety disorder with panic disorders. The difference between the two is found in the fears that underlie them, explains psychologist Thomas A. Richards. People with a panic disorder interpret their sudden, discombobulating anxiety attacks as something being physically wrong with them. They might, for example, believe that the tightness in their chest means that they’re having a heart attack or that they are about to suffocate to death.
Not so in the case of social anxiety sufferers, who do not see their heightened anxiety as a primarily physical issue. They see their anxiety, provoked by social interactions, is the underlying fear.
“The socially-anxious person has extremely high anxiety when they’re put into a position where they must make small talk to a stranger or interact with others in a group,” Richards writes. “Their anxiety becomes worse when the person fears that they are going to be singled out, ridiculed, criticized, embarrassed, or belittled.”
It is important to note that people living with social anxiety are not deluded: they recognize this fear as unreasonable and excessive. Yet, they act on this fear they know to be irrational by avoiding social situations or becoming very anxious when socializing.
Like in cases of other anxiety disorders, both talk therapy and medications have been found helpful to the socially anxious.
Cognitive behavioral therapy has been proven effective in many cases. Often therapists will try to get at deeply seated roots of the problem (which, for example, may have to do with family background or history of having been bullied). In practical terms, they can conduct exposure therapy, in which patients prepare for and are put in social situations that challenge them. Some studies have found that, depending on the individual, talk therapy can be as effective as antidepressants.
Antidepressants (particularly SSRIs) can help, too, by increasing the presence of neurotransmitters (serotonin, dopamine, and norepinephrine) in the brain, which in turn allows for mood management; people treated with antidepressants are then better able to internalize the rational arguments against social anxiety disorder–for example, that few people take the time to scrutinize us when we make a comment at a cocktail party. It takes of a few weeks of well-tuned and consistent use for antidepressants to render effective results. Tranquilizers known as benzodiazepines–for example, Xanax and Ativan–can in the meantime be used occasionally to prevent acute attacks of anxiety, such as panic attacks.
The socially anxious patient who has a speaking engagement can benefit from taking a benzodiazepine prior to that occasion. Beta blockers block adrenaline, which can reduce the physical symptoms of social anxiety such as shaking voice, elevated heart rate and blood pressure, excessive sweating, and the pounding of the heart.
The National Institute for Mental Health’s online social anxiety section contains explanation of the disorder, symptoms, and treatment information
Obsessive-compulsive disorder, or OCD, is a chronic pattern of unwanted, unreasonable, and repetitive thoughts, feelings, ideas, mental images, or sensations (obsessions) that drive people to repetitive behaviors (compulsions).
About 2.2 million American adults live with OCD, which often coexists with eating disorders, other anxiety disorders, or depression.
Common symptoms of obsessions include fear of germs or uncleanliness; unwanted taboo thoughts involving sex, religion, and harm; unwanted aggressive thoughts; preoccupation with order, symmetry, or counting things
Common symptoms of compulsions include rituals such as needless cleaning of one’s hands or environment; ordering and arranging things in a particular, exact ways; repeated checking on things, for example to make sure that the stove is off before leaving the house; frequent counting
While sleeping issues are not considered core to OCD, some research indicates that intrusive thoughts do keep people with OCD up at night.
Everyone double-checks things and some people prefer more order than others. OCD-afflicted persons, however, stand out because of their inability to control the thoughts that they know to be unreasonable and because of how much time (often an hour a day) they devote to the OCD-driven ideas and activities. The rituals and behaviors bring a fleeting relief from anxiety, but do not give them pleasure. If you are a collector of things, for example antiques, and take pleasure in tracking them down and organizing them, you do not have OCD.
In diagnosing OCD, therapists look for obsessions, compulsions, and how much time they take as well as how much they interfere with the person’s normal daily pursuits, professional life, and relationships. DSM-5 teases out OCD’s diagnostic criteria.
It can sometimes be difficult for therapists to diagnose patients with OCD because of symptoms that hide (such as compulsive avoidance) and because patients are sometimes so horrified or embarrassed by their thoughts, feelings, or behaviors that they hide them from the therapists.
Like with other anxiety disorders, cognitive behavioral therapy (CBT) has shown to be effective in case of the OCD. In particular, a type of CBT called Exposure and Response Prevention Therapy (ERP) works well with OCD-afflicted patients. It relies on exposing the patient to the situation that normally triggers OCD behaviors and helping them learn to forgo these behaviors.
Along with ERP, antidepressants from the serotonin reuptake inhibitors group, are considered the first line of treatment for OCD. About 7 out of 10 people with OCD get relief from medication or ERP.
Stories of people living with OCD as well as tips for family members of OCD sufferers can be found at this ADAA page, the Brain & Behavior Research Foundation page, and the IOCD Foundation page
Phobias are intense, persistent, irrational fears regarding an object, place, or situation. The fears that animate them are disproportionate to the threat posed by the triggering situations.
The paralyzing fears can lead to intense discomfort, anticipatory anxiety, avoidance of triggers, and panic attacks. The most common phobias include archanophobia (fear of spiders), ophidiophobia (fear of snakes), archophobia (fear of heights), agoraphobia (fear of open spaces often developed by people with social anxiety), and claustrophobia (fear of small spaces).
The DSM-5 splits phobias into three categories:
agoraphobia (irrational anxiety about being in places from which escape might be difficult or embarrassing)
social phobia (irrational anxiety elicited by exposure to certain types of social or performance situations, also leading to avoidance behavior, which is the same thing as social anxiety disorder)
specific phobia (animal-related, natural environment-related, blood injection or injury-related, situation specific, other type such as choking or vomiting)
Specific phobias affect 19 million Americans, with women being twice as affected as men.
Much like with other anxiety disorders, phobia sufferers are advised to get good sleep. That can be tricky, to say the least, for those withsomniphobia, also known as hypnophobia, which is the irrational fear of sleep. People afraid to fall asleep are advised to practice healthy sleep hygiene, challenge negative beliefs, meditate, practice deep breathing, and follow other relaxation techniques to learn to feel relaxed and safe before falling asleep. If sleepwalking or sleep apnea are causes of somniphobia, these underlying causes need to betreated first.
Diagnosing phobias often means that the therapist will inquire about the source of fears and compare them against the list of phobias provided in the DSM-5.
It can be difficult to differentiate phobias from other disorders with fears of objects of situations at their cores (for example, schizophrenia, paranoia, OCD). Paranoia can cause avoidance, much like agoraphobia and social phobias. However, absent in phobias are attributions of ill intent onto others (present in paranoia) and the hallucinations (present in schizophrenia). The paranoid and schizophrenic believer their fears to be rationally based, whereas the phobic know that their fears are unreasonable but are nevertheless unable to control them. And, unlike people living with OCD, people with phobias do not obsess on them and do not act compulsively.
ERP, or therapies featuring exposure to the feared stimuli–such as flooding, systematic desensitization, progressive relaxation, virtual reality immersion, hypnotherapy, counter-conditioning, biofeedback, and modeling–have been proven effective in cases of phobia.
While exposure therapy is successful on its own, sometimes initial or occasional use of medications can also help. Some doctors recommend short-term use of sedatives in specific, infrequent situations (such as flying on an airplane or giving a speech) such as the fast-acting and short-lasting benzodiazepines. Beta blockers, which block the effects of adrenaline (increased heart rate, sweating, shaking voice), also get prescribed for phobias.
Self-help methods can also work, sometimes on their own. For ideas, see this Help Guide page.
PTSD is a potentially debilitating disorder that results from a shocking, terrifying, or dangerous event or series of events. People living with PTSD have difficulty recovering from trauma, and often reexperience it over and over. They feel stressed or frightened anew each time something brings trauma to mind–even when they are no longer in danger.
About 7.7 million Americans aged 18 and older have PTSD. Common with war veterans, the disorder is suffered by 67 percent of people exposed to mass violence. Rape is the most likely culprit behind PTSD: 65 percent of men and 45.9 percent of women who are raped are diagnosed with the disorder.
intrusive memories (recurring memories, flashbacks, nightmares, triggers provoking the reliving of the trauma)
avoidance (refusal to enter situations that remind one of trauma)
negative changes in thinking and mood (inability to feel positive emotions; emotional numbness; hopelessness; memory lapses, including trauma-related amnesia; difficulty maintaining intimate relationships)
changes in emotional reactions (angry outbursts, hypervigilance, overwhelming guilt or shame, self-destructive behaviors, suicidal thoughts, being easily startled, difficulty concentrating and trouble sleeping)
PTSD commonly robs people of sleep, sometimes inducing a sleep phobia, because of the nightmares that are common with this condition.
To be diagnosed with PTSD, patients have to report the symptoms listed in the DSM-5 in conjunction with the history of having experienced or witnessed in person a traumatizing event such as death, serious injury, or sexual abuse. Another qualifying history is the patients’ having learned that someone close to them experienced or was threatened by a traumatic event. Finally, the repeated exposed to graphic details of traumatic events (for example, in cases of professional first responders) also qualifies as PTSD-initiating history.
Unfortunately, PTSD can be sometimes confused with Traumatic Brain Injury. In most instances, it occurs at the same time as other disorders (such as depression).
Like with other anxiety disorders, the effective treatments for people living with PTSD are medications, talk therapy, or both. The types of psychotherapy found useful are exposure therapy, eye movement desensitization and reprocessing (EMDR), group therapy, and family therapy.
In addition to SSRI antidepressants (longer-term stabilizers of emotional responses) and tranquilizers (short-term anxiety reducers), doctors sometimes use second-line for PTSD include the drug Prazosin (Minipress). The medication has been found to decrease nightmares and a reduction in daytime PTSD symptoms. This effect–observed in a 2013 study of active-duty soldiers returned from Iraq and Afghanistan–is attributed the blocking by the drug of the animating neurotransmitter norepinephrine.
Panic disorder is an illness characterized by sudden, out-of-the-blue onsets of severe anxiety and panic attacks. The physical symptoms of this acute terror include panic attacks, which manifest as chest pain, heart palpitations, shortness of breath, dizziness, or abdominal distress. The attacks are defined as periods of “intense fear in which 4 of 13 defined symptoms develop abruptly and peak rapidly less than 10 minutes from symptom onset.” Persons with panic disorder can have between several attacks per day to several per year.
Panic disorders affect 6 million Americans, or 2.7 percent of U.S. population. Most of the sufferers are women.
Anticipatory anxiety, lasting at least one month, regarding having another panic attack or consequences of such an attack
Significant negative behavioral changes related to the attack
Panic attacks characterized by symptoms including heart palpitations; faintness or dizziness; tingling in the limbs; sense of loss of control or impending death or terror; sweating or chills; chest pains; shortness of breath. Accompanying, secondary signs may include headache, cold hands, diarrhea, insomnia, fatigue, intrusive thoughts, and ruminations.
Panic attacks can happen during the night, serving a cruel wake-up. Between 50 and 70 percent of people with panic disorder experience at least one nocturnal panic attack. As with the daytime attacks, the nocturnal ones cause the same symptoms and can have no discernable trigger. There is some evidence, however, that sleep disorders themselves can trigger nocturnal panic attacks.
It can be understandably hard to return to sleep following a panic attack, but the way to do it is still the same as with getting to sleep at a regular time.
Panic disorder can be confused, by the sufferers themselves, for hypochondria. They can experience shame over having gone to the emergency room fearing death only to learn that there is nothing physically wrong with them. This sometimes prevents them from seeking help.
When they do seek help, people living with panic disorder are diagnosed based on the DSM-5 criteria. Panic disorder is diagnosed in case when panic attacks do not result from substance use (intoxication or withdrawal), other medical conditions, or another psychiatric disorder (for example, PTSD or social anxiety, which can both produce panic attacks).
Panic disorder is often diagnosed as “with agoraphobia” or “without agoraphobia” because agoraphobia means that people with panic attacks avoid ordinary activities or situations because they worry about having panic attacks. A very small minority of people with agoraphobia become completely home bound.
There’s hope when it comes to panic. According to ADAA, “many people suffering from panic attacks don’t know they have a real and highly treatable disorder.” People who experience panic do not need to be in therapy for a long time.
Cognitive therapy can help people identify triggers and thus restructure the way they think and respond to various stimuli. Sometimes the therapy takes the form of “interoceptive exposure,” which focuses desensitization on physical sensations that people experience during a panic attack. According to American Psychological Association, interoceptive exposure can help patients undergo symptoms of a panic attack (elevated heart rate, hot flashes, etc.) in a controlled setting and teach them that these symptoms do not need to develop into a full-blown attack. Another technique is in vivo exposure, in which the threatening stages are broken down into tiny, manageable steps and the patient learns to gain control of each one.
The Panic Disorder and Agoraphobia page hosted by the ADAA
An article in the Psychiatric Times contains treatment plan for panic disorder
American Psychiatric Association posted guidelines on treating panic disorder
Tips for Sleeping even with Anxiety
People with anxiety disorders are in particular need of sleep. Getting good rest at night can help stabilize mood, improve cognitive functioning in areas of learning and memory, and promote the kind rational thinking we all need to put fears and concerns in context.
Here are five tips that can help you fall asleep in spite of anxiety:
Practice a healthy sleep hygiene:
Try to go to bed and wake up at the same time, regardless of your schedule.
Establish a bedtime routine. For example, take a hot bath, use a lavender-scented moisturizer, disconnect from social media, and read a book.
Do not drink caffeine several hours before bedtime.
Do not get your heart rate and adrenaline pumping two hours before bed. This means no exercise.
Make the bedroom a sanctuary of calm and rest: Make sure it’s cool and dark; eliminate clutter and distractions such as TV; sleep on a comfortable mattress that gives you enough support and does not make you hot.
Try to limit your bedroom activities to slumber and sex.
If you cannot fall asleep within 30 minutes, get out of bed and do something else, like read.
Talk about sleep troubles with your medical doctor and a therapist in order to pinpoint the source of the problems.
Ask the doctor about sleep supplements, such as melatonin, which can help regulate sleeping hours. Bring up the possible cons of the long-term use of melatonin and see if they apply to your situation.
To combat anxiety, consider keeping a worry journal on your nightstand. Write down your anxious thoughts there and release them, scheduling a time when you are awake to tackle them then.
Keep a sleep diary to gain insights and track your progress. See an example here.