The author's personal connection to anxiety and insomnia

Insomnia can stem from anxiety and consequently take an enormous physiological toll on the body. I personally have been struggling with both, not so much now, but often. I have trouble falling asleep and when I do, I usually don't stay asleep for more than 3-6 hours. I frequently wake up at 5am with a racing mind, finding it quite the challenge to go back to sleep. When I sleep poorly, I'm irratable, easily frustrated, distractable, very physically fatigued, have a strong headache near my upper neck, bottom head (near the brain stem and medulla, which mediate sleep and breathing). I worry about being able to sleep and these worries combined with lack of sleep can create a vicious cycle where I don't sleep well, then worry about it all day, which makes me sleep worse. Right now, however, it's not too bad.

Classical Conditioning: A not so unique anxiety and insonmia vicious cycle

If you pay attention to the Journal of the anonymous anxious person struggling daily with sleep difficulties (another post in this very blog), You'll see a pattern in his Interesting Observation section. He/she observes:

"There’s fear and overt anxiety attached to the thinking. Many times, as I find myself about fall asleep, some negligible thought with surface, not important but my body will wake up, jolt up, in fear and astonishment, my heart pounding as if my life were in danger. Has my experience rewired my brain in such a way that it responds to everyday issues and annoyances as if they were threats to my survival? I think there’s some biologically wrong with my brain right now; the anxiety and fear pathways feel severely but unnecessarily sensitive to anything."

You may notice that for Pavlov's dogs, salivating is a natural response to anticipating a meal. If the experimenter rings the bell before the food comes, soon the dog will salivate just at the sound of the bell, even if no food is in sight yet. On that same note, an anxious person with a racing mind can develop a similar pattern where a survival threat is analogous to food, and a racing thought is analogous to the sound of the bell. This pattern can worsen on its own as thoughts can trigger the person into "flight or flight," and the person tries to force himself to relax, which, like fighting a rip tide in the ocean, strengthens this conditioning as he continues to obsess and worry about being able to sleep. It can become a vicious cycle as he begins to believe that thoughts may actually threaten his survival, prohibiting him from falling asleep!

As we can see, thoughts pose no survival threat (just as the bell has no innate connection to food). However, the body learns to associate the racing thought with a survival threat. Therefore certain thoughts in bed, despite their harmless nature, can cause the anxious person to enter in to a "fight or flight" mode with a racing heart and overactivated sympathetic nervious system in bed while trying to sleep, when the opposite is desired. The good news is that once the body unlearns the classically conditioned response, that the thought is not actually a survival threat (just as the bell has no inherent connection to food) "extinction," the unlearning of the classically conditioned response, should occur and loose its effect.

Quick overview of the Anxiety Disorders, according to the DSM-IV-TR and their hypothesized link to sleep difficulties

Anxiety disorders (as well as Major Depression) are known as the common colds of mental illness. Anxiety, however, is a normal reaction to a stressor, a performance-motivator and may be a healthy warning sign. A modest amount of anxiety is enormously helpful and adaptive; it motivates you to meet your goals and it propels you out of dangerous situations. However, when taken to its extreme, it can severely interrupt one's daily functioning. The optimal amount of anxiety would look like a bell-curve; too little or too much are harmful.  Here I focus on those with a usually crippling and excessive anxiety. Most of the following disorders are linked to sleep difficulties and come from the DSM-IV:


People with OCD (Obsessive-Compulsive Disorder) quite perturbed by recurrent thoughts and/or irrational behaviors that can be so time consuming that they interfere with daily life, such as work, school or social relationships. Obsessions are "intrusive, inappropriate, recurring and persistent thoughts, impulses, or images that cause marked anxiety or distress." These are much more serious than the usually worries of our everyday lives. The more the person tries to suppress them, the stronger they grow. A common obsession is a fear of germ contamination. Compulsions are the repetitious and often ritualistic behaviors aimed at lowering the discomfort that stem from the obsessions. Repeated, excessive and unnecessary hand-washing would be a common compulsion to those with obsessions about germs. These incessant thoughts and resultant behaviors may dominate every moment of the person's daily life. Imagine trying to sleep, while fearing that bugs, germs, creatures and dust will have their way with you when you fall asleep! If the only way to allay this fear is frequent hand-washing, how much sleep do you think this person will get?

Panic Disorder is diagnosed when attacks become routine, but still difficult to predict. They appear to come out of nowhere. They many occur anywhere at any time, which makes it so crippling.  If a panic attack feels like it's imminent, as it does for many with panic disorder, Lying in bed in itself, expecting an attach may be sufficient in itself to reduce sleep onset and sleep quality.

Phobias are fears marked by significant anxiety in the presence of a given stimulus and should regularly occur during exposure to that stimulus. The phoblic person will attempt to avoid this stimulus at all costs. If the phobia isn't so closely linked to things that can be bothersome in bed, sleep difficulties many not be a likely symptom for this disorder.


PTSD (Post Traumatic Stress Disorder If it were up to me, I'd cut off the 'D,' as this seems like a normal, natural and understandable response to an abnormal situation) occurs after exposure to traumatic events. This person has most likely experienced or witnessed an event that involved actual or threatened death or serious injury, and must have responded with "intense fear, helplessness or horror." This traumatic event is usually re-experienced by the individual in nightmares, flashbacks or physiological stress. The person tends to work hard at suppressing these seemingly unavoidable recurrent experiences. Irritability, difficulty concentrating, hypervigilence, an exaggerated startle response and sleep disturbance are hallmarks of this disorder. How can one sleep soundly when they're continually invaded by past, traumatic and horrific memories, especially in their dreams?!

ASD (Acute Stress Disorder Again, same point) is quite like PTSD but tends to result right after the traumatic event. It may blossom into PTSD. Unlike PTSD, which implies that symptoms last for more than a month, ASD may get resolved quickly. Similarly, sleep is likely to be interrupted after a traumatic event.

GAD (Generalized Anxiety Disorder) affects those who are 'characterologically' anxious; they live with a broad, unspecific sense of dread and pertubation with physiological arousal, in a variety of usually non-threatening, relatively safe situations. Worry and anxiety should be chronic-- presence more days than not. 5% of the general population is estimated to have it, but sadly most don't pursue treatment.  If you're constantly worried about something, is that an ideal mindset for sleep?

Source:

Wedding, Boydm, Niemiec. Movies and Mental Illness 3. 2010 Hogrefe Publishing 

5 quick TIPS for a better night's sleep!!

Exercise daily. This can help to improve your ability to fall asleep as well as the quality of sleep you get. In addition, exercise offers many health benefits such as boosted immune system, sharper brain function, enhanced mood (running for 20-30 minutes three times a week was found to boost one's mood the way the 10-20mg of Prozac daily would otherwise, but naturally!) and a faster metabolism.

Avoid naps. Naps, especially when taken late in the afternoon, tend to interrupt sleep at night. Instead of a nap, take a walk to invigorate yourself. If you must nap, try to take one earlier in the day and limit your nap to 30 minutes.

Avoid alcohol, caffeine and nicotine. Alcohol may help put some people to sleep but the quality of the sleep is usually poor. Caffeine and nicotine are stimulants and can interfere with both falling asleep and staying asleep.

Go to bed at the same time each night and wake up at the same time each morning. Keeping to a set schedule will help tell your body that it is time to sleep. The longer you keep your routine, the easier you will find it is to fall asleep each night. This also applies to weekends!

Create a bedtime routine to help you relax. Preparation for bedtime will help to alert your body that it is time for sleep. Think about the things that help you relax. It could be reading a book, listening to soft music, taking a warm bath or engaging in a quiet activity such as knitting. Spend some time each evening, right before bedtime to wind down, relax can help improve your ability to fall asleep. The 30 minutes before sleep are not for excessive studying or worrying!

Movies Related to the Topic!

Although all the movies listed below give insight into the world of the insomniac, I've yet to find a movie with insomnia (except for Insomnia (2002)) that's directly related and caused by anxiety independent from depression, substance or other comorbid medical conditions.  Any others recommendations?

Insomnia (2002): Al Pacino plays an LA policeman, with primary insomnia (when the insomnia complaints were not accompanied by a mental or general medical condition or by substance use). He flies to Alaska to lead a murder investigation, already extremely exhausted. This time of year in Alaska, the sun never sets, so it never gets dark at night. As the investigation progresses, the protagonist continues lying in bed with his eyes wide open, struggling desperately to fall asleep. He attempts to block all light from the room, he hides his alarm clock and turns off his phone. As his insomnia exacerbates, he 'sees' flashes and trickles of light. His vision grows blurry, he gets extraordinary distracted during conversations, and often dozes off into space. The longer he goes without sleep, the worse the consequences; he becomes belligerent, almost runs over a woman, and begins hallucinating. 6 nights without sleep! The pressure of the murder investigation and his residual guilt from killing his partner and covering in it up to protect himself overtly worsens his insomnia and vice versa. The film uses a lot of imagery: Alaskan glaciers (maybe that represent a dreamscape), green trees covered in fog, empty streets with schizophrenic traffic lights, "trance-inducing" windshield wipers. I presume they portray the "haziness, drifting, mental confusion and disorientation" (p. 180) associated with insomnia.

The Machinist (2004): The protagonist is a lonely depressed man unable to sleep for a long while. He uses Stimulants a lot like caffeine and nicotine, which isn't uncommon among those with in insomnia. His sleep difficulties are obviously negatively impacting his daily functioning. He's abnormally skinny, he caused a car accident, becomes paranoid are his colleagues are plotting against him. Even though anxiety isn't the main cause of his sleep problem, it portrays the debilitating effects of chronic insomnia quite accurately. The good news is that our anonymous journal writer hasn't experienced insomnia to this extreme.

Fight Club (1999): This shows circadian rhythm sleep disorder as his work requires frequent travel. He feels like he's never aware nor asleep and starts loosing a lot of weight. He often stares into space and his body language would suggest that he's completely drained. In the movie, his sleeplessness results in a departure from reality, leading to DID (dissociative identity disorder). Those with severe insomnia may experience dissociative or psychotic symptoms, but there's not evident that it causes DID.

Source:

Wedding, Boydm, Niemiec. Movies and Mental Illness 3. 2010 Hogrefe Publishing

What are the physiological and psychological effects of chronic anxiety-induced insomnia?

Various studies have linked sleep deficits with poor work performance, driving accidents, relationship problems, and mood problems like anger and depression. And a growing list of health risks have been documented in recent studies, like heart disease, diabetes and obesity. Others to keep in mind:

-Elevated cortisol (the body's main stress hormone)
-Over activated, hyper-sensitive, sympathetic nervous system (the body's fight or flight) response
-Under activated, suppressed parasympathetic nervous system (the body's calming response)
-Usual headaches, often a unique pain in upper neck
-Overall body fatigue
-Poorer cognitive functioning, especially regarding concentration and memory
-Delayed reflexes 
-Mental confusion
-Greater tendency to worry obsessively, especially before bedtime
-The mind often forms a negative relationship with the bed
-poorer reflexes
-overall irritability
-depending on its severity, it could start to negatively impact one's diet and/or bowel movements
-Fear of going sleep

CAN ANYONE THINK OF OTHERS?

Treatments

As a general rule, like most quick-fix solutions, in the short-term, medications can help but in the long-term they can actually exacerbate the situation and foster pharmacological dependence and tolerance. They're frequently over-prescribed and misused, especially in the USA. A lot of the research studies regarding these medications aren't so reliable either, as it's a profit-driven business. Regarding anti-anxiety or sleeping pills, the key is to use them sparingly; only when truly necessary, preferably no more their twice a week to minimize risk for dependence. The Dean of my Master's program asserts that to maximize treatment effectiveness, medications should almost always be accompanied with another form of treatment such as psychotherapy or MBSR (mindfulness-based stress reduction). 

Those less successful in the long-term:

Sleeping pills:

-high tendency for abuse, tolerance, dependence
-don't address underlying cause, only symptoms

Antidepressants: 

-Can regulate sleep but, still don't address underlying cause, only symptoms

-irritating side effects like impotence, decrease in sexual desire

Anti-anxiety medication:

-risk for tolerance and addiction

-don't address underlying cause, only symptoms

Those more successful in the long-term: 

Cognitive-Behavioral Therapy: Challenging and reframing the maladaptive thinking patterns associated with anxiety and insomnia

-almost always recommended if patient is taking some kind of medicine.

-a great deal of empirical support

Stimulus Control Therapy: treatment for patients who have conditioned themselves to associate the bed, or sleep in general, with a negative response. As stimulus control therapy involves taking steps to control the sleep environment, it is sometimes referred interchangeably with the concept of sleep hygiene. Examples of such environmental modifications include using the bed for sleep and sex only, not for activities such as reading or watching television; waking up at the same time every morning, including on weekends; going to bed only when sleepy and when there is a high likelihood that sleep will occur; leaving the bed and beginning an activity in another location if sleep does not result in a reasonably brief period of time after getting into bed (20-30 minutes); reducing the subjective effort and energy expended trying to fall asleep; avoiding exposure to bright light during nighttime hours, and eliminating daytime naps.

Paradoxical intention: a cognitive reframing technique where the insomniac, instead of attempting to fall asleep at night, makes every effort to stay awake (essentially stops trying to fall asleep). One theory that may explain the effectiveness of this method is that by not voluntarily making oneself go to sleep, it relieves the performance anxiety that arises from the need or requirement to fall asleep, which is meant to be a passive act. This technique has been shown to reduce sleep effort and performance anxiety and also lower subjective assessment of sleep-onset latency and overestimation of the sleep deficit.

Practicing mindfulness, meditation:

-studies have concluded that a mindfulness practice reduced mental and bodily restlessness before sleep and the subjective symptoms of insomnia, restlessness, sleep effort 
-addresses the problem at its core! (the need to increase the body's relaxation)

EFT (Emotional Freedom Techniques) and Tapping: focuses on tapping on the body's 12 acupuncture points while the client focuses on a specific issue related to anxiety or insomnia.