03 Oct The Link between Insomnia and Anxiety Disorders: Implications for Integrated Treatment Approaches
Insomnia, characterized by difficulty falling asleep, staying asleep, or experiencing non-restorative sleep, is a widespread sleep disorder affecting millions of individuals globally. Concurrently, anxiety disorders, a group of mental health conditions characterized by excessive worry and fear, also impact a significant portion of the population. The relationship between insomnia and anxiety disorders has been the subject of extensive research, with findings highlighting a bidirectional connection between the two. The significant occurrence of anxiety coupled with insomnia supports the need for continued intentionality in addressing sleep hygiene in mental health care.
Frequent daytime worrying often extends into the night, leading to what is known as “mental hyperarousal,” disrupting the ability to fall asleep. Even after successfully initiating sleep, individuals with an anxiety disorder may struggle to maintain uninterrupted sleep, preventing them from experiencing a fully rested state. Inherently, anxiety plays a protective role in keeping individuals safe from potential threats. However, when the alarm is persistently activated without valid cause, this may lead to dysfunctional arousal, potentially causing persistent sleep-wake difficulties. This cycle contributes to stress surrounding the inability to initiate or sustain sleep, further fueling anxiety. The reciprocal relationship between sleep difficulties and anxiety creates a self-perpetuating loop that can exacerbate both conditions. According to NAMI, the National Alliance on Mental Illness, there is a 50% comorbidity between insomnia related to depression, anxiety, or other psychological stress.
Researchers in 2023 explored the most efficient methods for treating insomnia that is comorbid with an anxiety disorder, citing that many treatment methods for addressing insomnia are not evidence-based. Treatment frequently targets the comorbid mood disorder, with the expectation that improvement of the mental health symptoms will consequentially improve the sleep symptoms. The findings reported in the Journal of Clinical Medicine (2023) that many practitioners supported the clinical approach that when treating comorbid chronic insomnia, the psychiatric condition should be the sole focus of treatment as the insomnia is most likely a symptom of the psychiatric illness. However, the researchers found that the improvements in sleep quality achieved with monotherapy were significantly less than those obtained with co-modal interventions targeting both sleep and anxiety or depression. The study concluded that it may be clinically meaningful to add a specific insomnia therapy when treating comorbid sleep and mood disorders.
Cognitive Behavioral Therapy for Insomnia (CBT-I) is a highly effective treatment for insomnia that is based on the principles of behavior change, psychological theories, and the science of sleep. Several studies have provided strong empirical evidence for the effectiveness of CBT-I in treating insomnia. This treatment modality focuses on identifying and addressing the underlying behavioral, cognitive, and emotional factors contributing to sleep difficulties. By modifying these factors, CBT-I helps individuals establish healthy sleep habits and improve the quality and quantity of their sleep. Although CBT-I is clinically effective, it is not being widely used to address the significant public health impact of insomnia.
Research in the Sleep Medicine Reviews (2018) journal found that CBT-I and the components of this treatment approach showed a clinically significant impact on insomnia symptoms, including insomnia severity, number of awakenings, and overall sleep quality. Recent innovations in utilizing CBT-I offer additional implications on the efficacy of this mode of treatment. Researchers in 2015 found that delivering CBT-I interventions in a group setting offered similar benefits in the reduction of insomnia and symptoms of mood disorders. A study conducted in 2022 reported in Current Psychiatric Reports found that the use of CBT-I was superior to other more traditional treatment approaches for anxiety in improving insomnia symptoms for people with insomnia coupled with a mood disorder.
In conclusion, the bidirectional connection between insomnia and anxiety disorders highlights the need for comprehensive and integrated treatment approaches that target both conditions. Insomnia is a significant public health concern with severe consequences, including poor physical and mental health outcomes. Treating the symptoms of anxiety or other mood disorders is not the most effective means of reducing the severity of the sleep disturbance symptoms. Therefore, it is necessary to encourage healthcare providers to assess for insomnia and educate them on the first-line therapy for chronic insomnia, which is CBT-I. Behavioral health clinicians must prioritize CBT-I as a treatment modality in their practice. By approaching insomnia with evidence-based treatment modalities, clinicians can improve the quality of care for individuals with insomnia and anxiety disorders, ultimately improving their quality of life.