- How Sleep Works
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- Sleep Health
- Sleep Medicine
The National Institute of Mental Health estimates that one in five Americans have some sort of mental illness. The severity and duration can vary widely, and it is a much smaller percentage that is under medical treatment.
Sleep disorders are potential symptoms of almost every psychiatric illness. About 40 percent of patients who seek medical help for sleeping problems have a psychiatric condition. Meanwhile, to have a mental health disorder without sleep problems is quite rare: fewer than 20 percent of mental health patients don’t have sleep problems.
To an extent, sleep quality can be a barometer of mental health. For this reason, psychiatrists always inquire about sleep behavior when making a diagnosis.
Sleep disorders often coexist with anxiety and panic disorders, depression, ADHD, schizophrenia, eating disorders, substance use disorder, OCD, personality disorders, and bipolar disorder. Problematically, the sleep issues associated with these mental health disorders make it more challenging to manage symptoms and experience the benefits of treatment.
Poor sleep is both a symptom and a cause of mental illness. Sleep problems may contribute to the development or prolongation of mental illness by making it more difficult to cope with mental problems.
Sleep disorders are comorbid with many other illnesses; the most common comorbidities with insomnia are mental illnesses. It’s estimated that 40 percent of insomnia patients and over 45 percent of hypersomnia patients have a psychiatric condition. On the other hand, people without mental illness have substantially lower rates of insomnia. It’s a striking enough difference that nobody doubts the tie between sleep disorders and mental illness any more.
People with mental illness often report the sleep they do get is not restorative. They wake up still feeling tired, whether from waking frequently during the night, falling asleep too late, or waking too early. In fact, as we’ll go into in the sections below, many studies show that patients with mental health disorders experiences demonstrable changes to their sleep architecture. Often, the individual spends more time in the lighter, less restorative stages of sleep, and less time in the critically important deep and REM stages of sleep.
The following chart indicates the odds ratios for specific anxiety disorders associated with lifetime sleep disturbances (adapted from Breslau et al). GAD, generalized anxiety disorder; OCD, obsessive-compulsive disorder.
|Insomnia alone||Hypersomnia alone||Both|
|GAD||7.0 (2.8-17.2)||7.0 (2.8-17.2)||4.8 (1.5-15.2)|
|Panic Disorder||5.3 (2.0-13.6)||4.3 (1.3-14.8)||8.5 (3.1-23.5)|
|OCD||5.4 (2.0-14.8)||1.2 (0.1-9.7)||13.1 (48-35.7)|
|Phobic disorder||1.5 (1.0-2.3)||29 (1.8-4.8)||4.0 (2.5-6.5)|
|Any Anxiety Disorder||24 (1.6-3.5)||3.3 (2.0-5.4)||4.5 (2.8-7.3)|
Insomniacs on the whole tend to suffer from this problem – getting less sleep overall and spending insufficient time in the deeper parts of sleep. This is what makes the disorder so particularly frustrating: they feel like there is no relief from their discomfort.
This lack of sleep in turn makes it more challenging to cope with the symptoms of their mental illness. The REM stage of sleep provides us with the emotional and cognitive benefits of sleep. With sufficient REM sleep, we feel emotionally balanced, and able to regulate our emotions and make good judgments. Our brain works and processes information as it should. Without it, we’re moodier, prone to irrationality and poor decision-making, and have difficulty remembering things. It’s easy to see how this mindset makes it tough to cope with mental health.
Together, mental illness and insomnia exacerbate the effects of each other, creating a classic negative feedback loop, and once they get started, push the patient in a downward spiral. This makes treatment of both conditions difficult.
Left untreated, the sleep problems associated with mental health disorders can be particularly dangerous. A University of Michigan study found a strong correlation between insomnia and suicide.
In the following sections, we’ll review the sleep disorders commonly associated with different mental health conditions.
Nearly one in five Americans suffers from some sort of anxiety disorder, such as generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder (OCD), phobia, post-traumatic stress disorder (PTSD), or panic disorder.
Anxiety results from a reaction to stress. Big or small, stress of all kinds affect the nervous system. Individuals with an anxiety disorder, however, experience stress at a more acute level. It may stem from obsessive anxious thoughts, or they may be coping with PTSD from a trauma. Regardless of the cause of their stress, their nervous system does not “reset” back to normal as it does for those without an anxiety disorder.
This heightened state of anxiety keeps their nervous system constantly alert, in direct opposition to the sort of relaxation necessary for falling asleep. This experience occurs even at the hormonal level. Cortisol, the body’s stress hormone, operates in inverse to melatonin, the hormone responsible for inducing sleep. With more stress in our system, the tougher it is for our brain to produce adequate amounts of melatonin.
People with anxiety disorders may be prone to the following sleep problems:
Psychotherapy, particular cognitive behavioral therapy (CBT), is one of the most effective treatments for individuals experiencing sleep problems related to their anxiety disorder.
CBT is often recommended for anxiety disorders. CBT-I, the specialization devoted to insomnia, applies the same principles the patient is already familiar with from regular CBT, such as reframing their negative thoughts, to sleep. Therapists work with patients to educate them about healthy sleep habits, help them recognize the thoughts and behaviors interfering with their sleep, and learn how to replace them with healthier reactions.
About 16 million adults have major depression. The negative affect, loss of interest in formerly enjoyable activities, suicidal ideation, and other symptoms severely impact their quality of life.
Insomnia affects 75 percent of individuals with depression, and it’s a major risk factor for suicide among this population. One study found that individuals with insomnia are 6 times more likely to develop major depression, and those with depression and comorbid insomnia are more likely to stay depressed.
Depressed individuals are more likely to spend a longer time falling asleep, spend less time asleep overall, experience disturbed sleep, and spend less time in REM sleep (as evidenced in the chart below):
Even when the mood change isn’t enough to merit depression, insomnia is associated with sadness. Researchers have followed groups of insomnias in longitudinal studies that stretch over years. They consistently find having insomnia increases the risk of later development of mental illness.
Women with depression are more likely to experience sleep problems. Individuals with seasonal affective disorder (SAD), a seasonal form of depression, will experience different sleep problems to varying extents during different seasons of the year.
In addition to insomnia, individuals with depression may be prone to the following sleep problems:
Unfortunately, many of the antidepressants prescribed to treat depression can cause or worsen insomnia. That increased insomnia can make them more depressed.
Antidepressant medications are often used to treat insomnia. Amitriptyline, trazodone, or mirtazapine are known as sedating antidepressants, and the more common SSRI drugs in use today are employed for patients with sleep disorders, too. Some patients react to antidepressant medication by becoming more active and energetic, making it more difficult to initially fall asleep, even as the relief of the depression alleviates other aspects of their insomnia, such as their ability to stay asleep.
Often treating the depression makes the insomnia go away. This is particularly true in cases of mild depression (dysthymia) which is very common, and often results in troubled sleep. Many people find their insomnia disappears quickly when they start taking antidepressant medication.
Similar to anxiety disorders, CBT is effective for treating both depression and insomnia. The principles of CBT can be applied to reframing negative thoughts that contribute to depression and poor sleep.
Light therapy is another therapy that can help individuals with depression, especially those with seasonal affective disorder or hypersomnia. The therapy involves sitting in front of a specialized light device for a set period of time each day, in an effort to reset the individual’s circadian clock. Practicing light therapy in the morning helps wake up the individual for the day, while an early afternoon practice helps them stay awake and avoid falling asleep too early.
Attention-deficit/hyperactivity disorder (ADHD) is a neurobiological disorder commonly diagnosed in childhood. It affects 5 percent of children and can persist into adulthood for many. The disorder is characterized by behavioral symptoms that predominantly fall into categories of inattentiveness, impulsivity, and hyperactivity.
The symptoms of ADHD, along with the medication used to treat it, result in fragmented sleep and potential sleep disorders.
People with ADHD are prone to the following sleep problems:
The medications used to treat ADHD symptoms often result in sleep problems. Longer-acting ADHD medication tends to have stronger effects on sleep. It is important that individuals with ADHD inform their doctor about any sleep issues they’re experiencing, so those can be considered when developing a treatment plan.
CBT-I is a behavioral method recommended for treating the sleep problems experienced by those with ADHD. To calm the mind and body and counteract the hyperactivity symptoms of ADHD, therapists may particularly focus on progressive muscle relaxation and stimulus control techniques.
Other effective sleep therapies for individuals with ADHD include sleep restriction therapy, where therapists set a sleep schedule for their patient. Patients strictly follow this schedule, only spending time in bed during those hours, and not allowing for any naps or sleep time outside of it. Additionally, light therapy can help those with delayed circadian rhythms.
Sleeping with a weighted blanket can provide relief for those suffering from RLS symptoms. The general rule is to find a blanket that weighs 10 percent of your body weight, plus 1 pound.
Schizophrenia affects 1 percent of Americans. This severe mental illness interferes with their ability to process reality, manage their emotions, and communicate with others. It’s accompanied by debilitating symptoms, such as hallucinations and psychosis.
Between 30 to 80 percent of people with schizophrenia experience disturbed sleep.
Sleep problems common to schizophrenia include:
The first generation of antipsychotics used to treat schizophrenia had no universal effect on sleep architecture, but the later generation of so-called atypical antipsychotics, including clozapine, olanzapine, and quetiapine, have observable positive effects on sleep. Schizophrenic patients who take them sleep longer. Some drugs increase the length of their slow-wave sleep, while some increase REM latency, similar to the effect of SSRI drugs on people with depression.
Treating the sleep issues does tend to alleviate the intensity of the psychotic symptoms of schizophrenia. However, clinicians advise adjusting the CBT-I strategies to account for the potentiality of triggering psychosis:
A personality disorder is defined as a way of thinking, feeling, or behaving that strays from the normal cultural expectation. Some common personality disorders are:
It’s estimated that about 1.6 percent of the U.S. adult population suffers from borderline personality disorder (BPD). BPD symptoms include unstable feelings in relationships that swing between intense feelings of love and hate, an unstable self image that impacts mood, chronic feelings of emptiness, and “out-of-body” feelings.
Rates of substance abuse and depression are higher in those with personality disorders, causing studies that look at the relationship between sleep disorders and personality disorders confusing to interpret. Depression and substance abuse can negatively impact sleep, so the causation of the sleep disorder in those with personality disorders may be attributed to any of those factors.
Studies of personality disorder concurrent with sleep disorders are rare with most research focusing on BPD and sleep and antisocial personality disorder and sleep.
Cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT) are the preferred methods for treatment of personality disorders. DBT focuses on teaching the patient new skills to deal with emotions and relationships. It includes four areas: mindfulness to accept the current mood, distress tolerance to tolerate negative emotions, emotional regulation to learn control, and interpersonal effectiveness to strengthen relationship skills.
Light therapy can improve well-being and circadian rhythms in those suffering from concurrent personality disorders and sleep disorders. Daytime alertness increased with light therapy as well.
CBT, DBT, and light therapy have shown positive associations with treating personality disorders and sleep disorders, which can often be comorbid.
Almost 3 percent of U.S. adolescents aged 13 to 18 have been diagnosed with an eating disorder, and slightly over 1 percent of U.S. adults. Eating disorders disproportionately impact females. Eating disorders are serious and can be fatal illnesses that causes severe disturbances to a person’s eating behavior. Common eating disorders include binge eating disorder, bulimia nervosa, anorexia nervosa, and sleep-related eating disorder.
Individuals with eating disorders frequently suffer from sleep problems. Some reports show half of those with an eating disorder also have a sleep disorder. Those with eating disorders may also suffer from depression, anxiety, or another mental illness. Sleep disorders in conjunction with mental health issues and eating disorders can become cyclical with one condition exacerbating the others. Weight loss, starvation, and malnutrition can all have a negative effect on sleep quality. Here are some common sleep problems in those with eating disorders:
Treatment for an eating disorder often eliminates the sleep disorder. Cognitive behavior therapy (CBT) is the leading treatment for eating disorders. CBT for eating disorders includes retraining how the individual views food and realigns eating habits. CBT-E is an enhanced version of CBT that has shown success in those with eating disorders. The enhanced aspect aims to treat the underlying cause of an eating disorder such as low self esteem, perfectionism, or interpersonal difficulties. Both CBT and CBT-E have shown positive effect on alleviating eating disorders. With healthy eating habits, the sleep disorder is often treated without specific sleep-disorder therapy.
Bright light therapy has shown success in treating eating disorders, specifically bulimia and anorexia. Bright light therapy has also been successful in treating sleep disorders, so this option may treat both conditions simultaneously. This therapy involves sitting in front of a specialized light device which helps the body’s circadian rhythm function properly.
Obsessive compulsive disorder (OCD) is a disorder in which an individual feels uncontrollable recurring thoughts (obsessions) and behaviors (compulsions) accompanied by the urge to repeat the thought or behavior over and over. It’s estimated that 1.2 percent of adults in the U.S. suffer from OCD. The degree of OCD impairing an individual’s life range significantly from mild to severe. Approximately half of those with OCD have severe impairment. Common symptoms of obsessions include a fear of germs and contamination, or having things symmetrical or in perfect order. Common symptoms of compulsion include excessive hand washing or cleaning, repeatedly checking things, or counting. Symptoms of OCD may come and go.
Cognitive behavior therapy (CBT) is one of the first treatment options for those with OCD, as is common with other mental illnesses. Forms of CBT are also related to helping sleep disorders. Treating OCD with CBT may lessen the degree of sleep disruptions without direct treatment. If OCD symptoms are alleviated, sleep may concurrently improve.
Exposure Response Prevention Therapy (ERP therapy) is a type of CBT found especially effective in treatment for OCD. This therapy exposes the individual to what triggers the obsessions or compulsions and uses specific techniques to help overcome the desire to perform the obsessive or compulsive behavior. This is said to lower the anxiety level in those with OCD. A lowered anxiety level may also aid in better sleep.
About 8 percent of the U.S. population over the age of 12 exhibits symptoms of a substance use disorder (SUD), over 21 million people. Over 44 million report illegal drug, non-medical use of a prescribed drug, or heavy alcohol use during the prior year. While that doesn’t qualify for a diagnosis of a SUD, some of these people may suffer from negative consequences of substance abuse, including sleep disorders induced by the substance.
In order of prevalence, these are the most common substances in substance use disorder diagnoses:
Melatonin has positive results in treating insomnia in those with alcohol consumption SUD. Melatonin levels are low in alcohol-dependent patients. This treatment helps realign the circadian rhythm cycle.
Cognitive behavioral therapy (CBT) in conjunction with counseling is another treatment plan for those with SUD. This application of CBT focuses on the relationship between thoughts, actions, and behaviors that spur the substance use. Modifying those thinking patterns can help recover from the substance use disorder.
Sleeping disorders associated with SUD may be alleviated without specific therapy once the SUD is under control.
The sleep issues a person with bipolar disorder experiences will change depending on whether they are in a state of mania or depression.
The most common sleep problems affecting individuals with bipolar disorder include:
Whether caused by or independent of bipolar disorder, the sleep problems these individuals experience make it more difficult to cope with the symptoms of the disorder. The highs and sleeplessness associated with mania catch up with the individual during the resulting depression stage, during they worsen the overall hopelessness they feel.
Meanwhile, lack of sleep prior to an episode of mania is one of the biggest warning signs that mania is about to occur. Even sleep deprivation from something as benign as jet lag can trigger an episode.
Even in between episodes, individuals with bipolar disorder also experience lower quality sleep. They have more difficulties falling asleep and experience more interruptions to their sleep.
As with most cases of insomnia, research indicates CBT-I is an effective behavioral treatment for insomnia among individuals with bipolar disorder. Sleep restriction and stimulus control techniques in particular proved effective.