In this article, we will present a discussion of the correlation between insomnia and anxiety. First, we will see what insomnia and anxiety actually are. Then we will move on to whether anxiety can cause insomnia and, if so, what are the causes? Lastly, we will discuss whether the reverse is also possible, i.e. can insomnia cause anxiety?

Simply put, insomnia is a clinical term used to describe the phenomenon of frequently having problems while falling asleep. It is a fairly common sleep disorder, and people who have insomnia find it hard to fall asleep, and once they do fall asleep, it is difficult to stay asleep for a healthy amount of time. Insomnia can either be acute, or it can be chronic. Acute insomnia means it is short-lived and may last from one night to a few weeks.

Chronic insomnia, on the other hand, means it is a long-term disorder and lasts a minimum of three weeks and may even go beyond three months! Insomnia can also come and go from one’s life. Furthermore, insomnia can be primary or it can be secondary. Primary insomnia is easier to target and deal with as it is not associated with any other health conditions. Secondary insomnia occurs when some other health problem causes disturbed sleep, such as depression, asthma, cancer, and arthritis. Pain and medication can also be sources of secondary insomnia, and so can substance abuse such as alcoholism.  

Anxiety is essentially an emotion and is a normal bodily response to stress. It can cause feelings of worry, feeling tension and usually also comes with physical symptoms such as an increased heart rate. In some cases, it can help us deal with stressful situations and help the body prepare for “fight or flight” mode. It can, however, also be maladaptive and self-destructive. Fearing or apprehending about a job interview or first day at university may be called anxiety, but it is not maladaptive for the individual. Anxiety becomes a call for concern when it interferes with one’s life and daily activities, significantly impacting them for the worse.

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In such cases, anxiety is not simply fear or anxiousness for a short while or a handful of instances, instead it is intense fear and excessive anxiety quite often – this is known as an anxiety disorder. When someone has an anxiety disorder, they have recurring persistent thoughts which are highly difficult, if not impossible, to ignore. There are several types of anxiety disorders, each with slightly different symptoms depending on the type. But the general symptoms of an anxiety disorder include; feeling nervous and tense, apprehension of what is to come, breathing rapidly, having an elevated heart rate, feeling tired, sweating, having trouble concentrating, having gastrointestinal (GI) problems, and also having difficulty sleeping.

It is not rare for anxious individuals to have difficulty falling or staying asleep. In fact, it is common for insomnia to accompany anxiety. As mentioned earlier, anxiety means having excess fear and/or worry, so if someone is constantly thinking about something that they fear or worry about, they can easily lose their sleep over it. The fear and/or worry keeps the brain active and engaged in thoughts related to these negative emotions, making it difficult for the individual to find peace and get a good night’s sleep.

A primary factor in having anxiety-induced insomnia is mental hyperarousal, which is the alertness of the mind and is usually marked by feelings of worry. Studies have shown that people who have anxiety disorders are likely to have higher sleep reactivity, which basically means that these individuals have an increased likelihood of troubled sleep when they are stressed. It is also known that people with highly reactive sleep systems experience drastic deterioration of sleep when stressed, while individuals with low sleep reactivity have mostly undisturbed sleeping patterns during stress.

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As aforementioned, sleep difficulties can be a symptom of many types of anxiety disorder. These include Generalized Anxiety Disorder (GAD), Post Traumatic Stress Disorder (PTSD), and Obsessive-Compulsive Disorder (OCD). A study showed that more than 50 % of people with GAD had sleep problems. Another research study on individuals involved in military combat and suffering from PTSD, brought to light that a whopping 90 % of these had difficulty sleeping and symptoms of insomnia. People who have depression also find it difficult to fall asleep. Scarily enough, studies have shown that sleep disruptions are found in most mental disorders.

Continuous worry about not being able to fall asleep, also known as sleep anxiety, can further exacerbate symptoms of insomnia and make sleep difficult due to this preoccupation. Similar anxiety, called anticipatory anxiety, where people create hindrances for their own healthy sleep schedules, is another example of anxiety-induced insomnia.

Anxiety causes changes in REM sleep (rapid eye movement sleep) which is the deep sleep where people also experience dreaming. Having nightmares while sleeping during a stressful period of one’s life, may reinforce insomnia and negative associations with sleep as the person will not want to experience that again and would prefer staying awake. That said, with several studies explaining how anxiety causes insomnia, there are also many which delineate that there is a possibility of the reverse also being true – insomnia can cause anxiety as well.

To answer this, we need to see what comes first – anxiety or insomnia?

Either one of these can come first. We have already talked about anxiety that is followed by insomnia, now we will look at insomnia coming before anxiety. 

As already established, sleep deprivation can in fact increase the risk of having anxiety disorders. Not only can this, but bad sleeping patterns and lack of sleep also worsen current anxiety disorders. It is basic knowledge that a good adequate sleeping routine is indispensable for a healthy state of mind, and for mental and emotional strength and resilience. Research has shown that those people with some sort of serious sleep problems, such as chronic insomnia, are at a high risk of developing an anxiety disorder.

Furthermore, people who are prone to anxiety are significantly sensitive to insufficient sleep. There is an interaction between the two and one can cause the other, and both can create a cycle of reinforcement – lack of sleep causes anxiety, and an anxious person prefers to not sleep as he/she might face nightmares related to their source of apprehension and worry.  

A lack of sleep is known to affect mental and emotional health, which can eventually instigate anxiety even in someone without a history of anxiousness. Many studies have shown how people with insomnia are at risk of contracting an anxiety disorder. Obstructive Sleep Apnea (OSA) is a sleep disorder that is characterized by interrupted sleep and lapses in breathing. People who suffer from OSA have been proven to have a higher rater of mental health problems such as anxiety, depression, and panic disorder (a type of anxiety disorder). Thus, it is possible for insomnia to cause anxiety just as well as anxiety can cause insomnia.

There are serious health risks associated with insomnia. Mental health problems can be increased because of insomnia along with your overall health concerns. The following are the effects of insomnia:

1) Increased Risk of Medical Condition

         The risk of medical conditions is the first on our list as it is the most important, the medical conditions that can occur as a result of insomnia are as follows:

·  Seizures,

·  Asthma attacks,

·  Stroke,

·  The weak immune system,

·  Sensitivity to pain,

·  Inflammation,

·  Heart disease,

·  Diabetes mellitus,

·  High blood pressure,

·  Obesity

2) Increased Risk of Mental Health Disorders

         Mental health disorders can be at a higher risk due to insomnia. These include:

·  Anxiety,

·  Depression,

·  Confusion and frustration.

3) Increased Risk of accidents:

         The immediate concern for a person suffering from insomnia is daytime sleepiness, and that can affect your:

·  Performance at work or school,

·  Memory,

·  Judgment.

         A lack of energy throughout the day can keep a person very drowsy which in turn also increases the risk of car accidents.

4) Shortened Life Expectancy:

         Having insomnia can shorten your life expectancy. An analysis of 16 studies that covered over 1 million participants and 112,566 deaths looked at the relationship between sleep duration and mortality. They found that a 12 percent risk of death is increased due to lesser sleep, which was compared to people who got around seven to eight hours of sleep per night.

         A recent study looked at the effects of insomnia that continued for a long time and mortality over 38 years. It was found that those with persistent insomnia had an increased risk of death, which was about 97 percent.

Lack of sleep can lead to, potentially, anxiety, but anxiety can also become the cause of a lack of sleep. The two can overlap quite a bit, causing one to increasingly worsen the other.

         A negative effect is created on your body’s ability to fall asleep through anxiety as your brain is in “fight or flight” mode, thinking of different potential outcomes for whatever is causing the anxiety. Furthermore, sleep disturbance and insomnia can be caused by anticipatory anxiety and specific anxiety about sleep, which then creates a loop of feedback that can worsen both conditions. Insomnia can also make you more irritable and more worried, as your brain is not getting all the sleep it needs in order to function at normal levels.

         However, it’s not uncommon to experience anxiety related to sleep. Sleep anxiety is a form of performance anxiety. Not getting enough sleep to function during the day is an issue that many people face and may stress about to their friends and family, but the stress alone of trying to sleep can cause the issue of lying awake for hours. Additionally, other fears such as recurring nightmares, fear of sleep apnea (not breathing while being asleep), etc. can all lead to sleep disturbance.

Insomnia caused by anxiety may affect your body physically due to excessive stress, and as a result of prolonged anxiety, it affects the following:

Central Nervous System:

         Anxiety can affect the central nervous system. Insomnia caused by anxiety certainly does not help with the issue. Long-term anxiety and panic attacks can cause your brain to release stress hormones on a regular basis. This can increase the frequency of symptoms such as headaches, dizziness, and depression. Once you have insomnia because of your anxiety, this situation may worsen.

         When you feel anxious and stressed, your brain floods your nervous system with hormones and chemicals designed to help you respond to a threat. While helpful for the occasional high-stress event, long-term exposure to stress hormones can be more harmful to your physical health in the long run. For example, exposure to cortisol in the long term can contribute to gaining weight.

Cardiovascular System:

         Insomnia caused by anxiety can cause an increase in the issue of rapid heart rate, palpitations, and chest pain. You may also be at an increased risk of high blood pressure and heart disease. If you already have heart disease, anxiety may raise the risk of coronary events.

Excretory and Digestive Systems:

         Anxiety also affects your excretory and digestive systems. Stomachaches, nausea, diarrhea, and other digestive issues could occur. You could also have a loss of appetite.

         A connection may occur between anxiety disorders and the development of irritable bowel syndrome (IBS) after a bowel infection. IBS can cause vomiting, diarrhea, or constipation.

Immune System:

         Anxiety can trigger your flight-or-fight stress response and release a flood of chemicals and hormones, like adrenaline, into your system.

         Your pulse and breathing rate are increased due to this in the short term, so your brain gets more oxygen. This helps you respond properly and correctly to intense situations. Your immune system may even get a slight boost with stress occurring from time to time, without being prolonged. Your body returns to normal functioning when the stress passes every time.

         But if you repeatedly feel anxious and stressed or it lasts for a longer time, your body never gets the signal to return to normal functioning. This may weaken your immune system, especially if you have trouble sleeping due to insomnia and as a result, you will be more exposed to viral infections and frequent illnesses. Your regular vaccines may not work as well if you have anxiety and insomnia.

The treatment of anxiety-induced insomnia is mostly the same as the treatment of insomnia. It can be treated in three of the following ways:

·  Pharmacologically,

·  Non-pharmacologically,

·  Combination of the two.

Pharmacological Options to Treat Insomnia from Anxiety

         The primary treatment of insomnia is pharmacological because of the speed of action. Pharmacological treatments become effective much faster than non-pharmacy therapy. The most common nonpharmacy therapy, cognitive-behavioral therapy for insomnia (CBT-I) takes considerably longer. The FDA has 11 approved drugs for the treatment of insomnia as of today:

·  Nonbenzodiazepines: eszopiclone, zolpidem, zolpidem ER, and zaleplon,

·  Benzodiazepines: estazolam, flurazepam, quazepam, temazepam, and triazolam,

·  A tricyclic antidepressant: low-dose Sinequan,

·  A melatonin agonist: ramelteon.

         In recent years, nonbenzodiazepines have become the most recommended of the approved hypnotics. Before, benzodiazepine was the most recommended hypnotic, but its reliability has become far lesser than it once was. Nonbenzodiazepines are very effective in treating insomnia (just as effective as benzodiazepines), but there is a notion that they are safer than benzodiazepines.

         In the treatment of anxiety-induced insomnia, insomnia should be treated side by side of the anxiety disorder, but independently. Meaning, do not consider the medical condition as one but as two separate disorders. Before people would only treat the anxiety disorder and wait to see if the insomnia was treated with that, but this method is no longer valid because clinical experience has shown that without targeting insomnia treatment, insomnia frequently stays and does not go.

         Around 50% of patients with insomnia continue to have insomnia 3 years after initially being diagnosed with the disorder. Many patients require months or even years of treatment. Nonbenzodiazepines for primary insomnia are found to have continued success and to be well tolerated with no evidence of abuse or withdrawal symptoms after stopping its use after 12 months. Ramelteon is also found to be effective and successful with no major issues of abuse or tolerance.

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         In some patients with insomnia, benzodiazepines are definitely necessary. The other hypnotics possibly will not give the same effect for some patients. In this case, the anxiolytic properties of benzodiazepines could be helpful.

         When hypnotics are used, their use needs to be checked every 3 to 4 weeks. Many patients with insomnia do not have sleep disturbances nightly. Therefore, the use of hypnotics on a requirement basis or a few times a week helps reduce the amount and exposure to the medication.

Non-pharmacological options

         The first option we recommend is CBT-I. CBT-I is an important, widely accepted, treatment for insomnia. It is the best-studied of the nonpharmacological approaches for this disorder and is a manualized treatment that focuses on various components of CBT, which are cognitive restructuring and the use of psychological interventions. These strategies address negative and mutilated cognitions and behaviors that start and sustain sleep deprivation. The time required for treatment is rather short. It is managed for 5 hours divided over 4 to 6 weeks and can hence be utilized as an upkeep treatment in the month to monthly sessions. There are about 12 well-designed CBT-I trials that have clearly illustrated that it may be a profoundly compelling mediation for insomnia for 1 year or longer.

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         Studies that compared CBT-I with pharmacotherapy found identical adequacy. In contrast to hypnotics, learned CBT-I skills may continue even when active treatment ends. Furthermore, a few patients may favor CBT-I over hypnotic drugs since their conceivable antagonistic impacts or concerns about drug use or taking a drug amid pregnancy.

         In general, CBT-I is not used enough. Only around 1% of patients with chronic insomnia decide to use this therapy. To increase the availability and use of CBT, it can be managed by means of self-help procedures and in a group format. However, it has been seen to be effective in providing CBT through the use of the internet. In most cases, patients often incline towards face-to-face contact.

         A few other non-pharmacological therapies other than CBT-I have also been used to treat insomnia, such as bright light, physical exercise, acupuncture, tai chi, and yoga. Sadly, the results have not been up to standards and have been inconsistent.

Combination Therapy

         A combination of pharmacotherapy and non-pharmacotherapy may or may not be more effective than either of the two types of treatments alone to cure anxiety disorders with insomnia. Combination therapy has not been addressed in studies of this particular patient population. The question has not been addressed very often, even in the treatment of insomnia. Studies find only mild differences in outcomes with a combination of therapies. The same types of results were seen in a study that compared CBT with CBT plus zolpidem. The 6-week short study illustrated a 60% successful reaction rate and a 40% remission rate; the group that was treated with the combination treatment had a significant increment to their sleep time of 15 minutes, but the analysts did not like this difference and did not find it clinical enough.