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  • Updated 04.08.2023
  • Released 07.17.2001
  • Expires For CME 04.08.2026

Sleep, trauma, and anxiety



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

Key points

• 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 problems are less common in social and specific phobias.

• The management of insomnia in the context of mental disorders rests in large part on successful treatment of the primary condition, 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 and trauma was provided by Freud, who described a distinct syndrome "anxiety neurosis" (22). 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 follow-up and family studies" was introduced in an article titled “Diagnostic Criteria for Use in Psychiatric Research” (21). This work formed the basis for the development of the third and fourth editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (65). Anxiety disorders were defined broadly and included posttraumatic stress disorder along with obsessive-compulsive disorder, as well as “insomnia second to anxiety disorder.”

In the 2013 fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, trauma-based disorders and obsessive-compulsive disorders were removed from anxiety disorders and given their own designation, reflecting differences in phenotype as well as etiology, despite common subjective complaints of “anxiety” (02). The condition “insomnia secondary to anxiety disorder” was replaced with “insomnia disorder,” which can specify if occurring with a comorbid psychiatric disorder.

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