Sleep and anxiety disorders

J Todd Arnedt PhD (Dr. Arnedt of the University of Michigan Medical School has no relevant financial relationships to disclose.)
Antonio Culebras MD, editor. (Dr. Culebras of SUNY Upstate Medical University at Syracuse received an honorarium from Jazz Pharmaceuticals for a speaking engagement.)
Originally released July 17, 2001; last updated August 18, 2012; expires August 18, 2015
Notice: This article has expired and is therefore not available for CME credit.


Anxiety disorders are well known to be associated with a variety of sleep complaints, most commonly insomnia and nightmares. A review of the anxiety disorders, including posttraumatic stress disorder, generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and specific and social phobia is provided, along with typical subjective and objective sleep profiles. In this article, the author discusses the bidirectional relationship between anxiety and sleep and highlights studies examining the role of sleep disturbances in the development and exacerbation of anxiety disorders, particularly posttraumatic stress disorder.

Key points


• Insomnia due to mental disorder is diagnosed when sleep complaints are caused by an anxiety disorder but are more prominent than would be typically expected and are of sufficient concern to be the focus of treatment.


• Insomnia and nightmares are hallmarks of posttraumatic stress disorder, and sleep disturbances are associated with the severity of symptoms and the likelihood of symptom remission at follow-up. By contrast, sleep disorders are less common in social and specific phobias.


• The management of insomnia due to mental disorder rests in large part on successful treatment of the primary anxiety disorder, particularly in the case of generalized anxiety disorder. Residual sleep problems following treatment are common in posttraumatic stress disorder and panic disorder and will often warrant independent treatment. Sleep-focused therapies only minimally improve anxiety symptoms in patients with and without accompanying anxiety disorders.


• Coadministration of anxiety- and sleep-focused pharmacotherapies in patients with both anxiety and sleep disturbances may yield greater resolution of anxiety symptoms than monotherapy for anxiety disorders.


• Nonmedication approaches targeting nightmares in patients with posttraumatic stress disorder have demonstrated benefit in uncontrolled trials but require more rigorous controlled evaluations in different patient populations.

Historical note and terminology

The first attempt at a systematic descriptive approach to anxiety disorders was provided by Freud, who described a distinct syndrome "anxiety neurosis" (Freud 1957). Further attempts at systematic classification of anxiety disorders occurred with the first edition of the Diagnostic and Statistical Manual of Mental Disorders in 1952, followed by a second edition in 1968 that was based on "the best clinical judgment and experience" of a committee and consultants, often utilizing unproved mechanisms in their classification schemes. A move toward a more descriptive classification "validated primarily by followup and family studies" was introduced in an article titled “Diagnostic Criteria for Use in Psychiatric Research” (Feighner et al 1972). This work formed the basis for the development of the third and fourth editions of the Diagnostic and Statistical Manual of Mental Disorders, the latter of which is in use today. Included in the current classification system is: panic disorder with and without agoraphobia, agoraphobia without a history of panic disorder, specific and social phobias, obsessive-compulsive disorder, posttraumatic stress disorder, acute stress disorder, generalized anxiety disorder, anxiety disorder due to a general medical condition, substance induced anxiety disorder, and anxiety disorder not otherwise specified. Sleep complaints have long been recognized as common in anxiety disorders, and the International Classification of Sleep Disorders Second Edition (ICSD-2) recognizes these complaints in the Insomnia category under the specific diagnosis “Insomnia Due to Mental Disorder” (American Academy of Sleep Medicine 2005). The ICSD-2 recommends use of this specific diagnosis when the sleep disturbance is believed to be caused specifically by the associated mental disorder but is more prominent than would be typically expected and is of sufficient concern to be the focus of treatment. The ICSD-2 also devotes an appendix to “Other Psychiatric and Behavioral Disorders Frequently Encountered in the Differential Diagnosis of Sleep Disorders,” which highlights the 4 anxiety disorders that include sleep or dream disturbances in their diagnostic criteria: panic disorder, posttraumatic stress disorder, acute stress disorder, and generalized anxiety disorder. Anxiety also occurs as a component of many other medical and psychiatric disorders, where it may adversely impact sleep (eg, depression or psychophysiological insomnia).

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