Insomnia and Anxiety (Series in Anxiety and Related Disorders) (12 page)

veys show a stable prevalence of obsessive–compulsive disorder with approximately

2% of the general population of Western societies meeting criteria for this condition.

Those with obsessive–compulsive disorder are not particularly prone to present in

Obsessive–Compulsive Disorder

41

primary care settings (Fireman, Koran, Leventhal, & Jacobson, 2001), but as many

as 9.2 % of those who seek psychiatric treatment suffer from this condition

(Hantouche, Bouhassira, Lancrenon, Ravily, & Bourgeois, 1995). These findings

are, perhaps, not surprising inasmuch as many as two thirds of those with obses-

sive–compulsive disorder present with comorbid mental disorders, particularly

mood or other anxiety disorders (Torres et al., 2006; Tukel, Meteris, Koyuncu,

Tecer, & Yazici, 2006). Obsessive–compulsive disorder tends to be chronic in as

many as 60% of affected individuals (Angst et al., 2004), and almost one half of

those who eventually achieve full symptomatic remission later suffer relapse (Eisen

et al., 1999). Whereas some persons with obsessive–compulsive disorder may suf-

fer surprisingly little social and vocational impairment, this condition often results

in considerable impairment of social and occupational functioning. In more pro-

tracted cases, this disorder may contribute to reduced quality of life, impairment of

family and social relationships, reduced productivity and heightened absenteeism

from work, chronic disability, and a markedly increased risk for suicide (American

Psychiatric Association, 1997; Kamath, Reddy, & Kandavel, 2007; Stengler-

Wenzke, Krolla, Matschingera, & Angermeyera, 2006; Torres et al., 2006).

Insomnia and other forms of sleep disturbance are not considered core symptoms

or primary associated features of obsessive–compulsive disorder (Stein & Mellman,

2005). However, one recent study (Voderholzer et al., 2007) indicated that those with

obsessive–compulsive disorder show relative disturbances of sleep continuity (i.e.,

more fragmented sleep) compared with well-matched noncomplaining normal

sleepers. Another recent study (Kluge, Schüssler, Künzel et al., 2007) showed that

obsessive–compulsive disorder sufferers displayed higher plasma concentration

levels of ACTH and cortisol during their sleep than did normal controls. Alterations

in REM and slow wave sleep architecture have also been noted in some (Insel et al.,

1982; Kluge, Schüssler, Dresler, Yassouridis, & Steiger, 2007) but not all obsessive–

compulsive sufferers (Hohagen et al., 1994; Robinson, Walsleben, Pollack, &

Lerner, 1998; Voderholzer et al., 2007). Considered collectively, these findings sug-

gest obsessive–compulsive disorder patients may have a relative propensity for dis-

rupted nocturnal sleep perhaps mediated by over-activity of the HPA axis. Of course,

insomnia may develop independently because of other factors and exist as a comor-

bid condition, as is the case with other anxiety disorders.

As noted by Smith and colleagues (Smith et al., 2005), compulsive behaviors

may sometimes play a role in insomnia complaints. For example, compulsive

checking that doors are locked or repetitive praying before retiring for the night

may interfere with the act of falling asleep and markedly delay sleep onset. Also,

given the recent findings implicating possible over-activity of the HPA axis in

obsessive–compulsive patients, excessive arousal during the nighttime may compli-

cate the sleep of some such patients. Furthermore, it is noteworthy that unhelpful

beliefs are thought to perpetuate the symptoms of at least some obsessive–compulsive

patients (Espie, Broomfield, MacMahon, Macphee, & Taylor, 2006). Hence, it

seems reasonable to speculate that such patients could have propensity for developing

the previously mentioned (see Chap. 2) types of unhelpful beliefs thought to

contribute and sustain insomnia. Given these possibilities, a thorough assessment

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3 Anxiety Disorders and Accompanying Insomnia

of factors such as the patient’s level of arousal at bedtime, presence of sleep-disrup-

tive compulsions, and unhelpful sleep-related beliefs may be particularly important

when evaluating the insomnia complaints of obsessive–compulsive disorder

patients. Cognitive and behavioral therapies that reduce bedtime arousal, alter

unhelpful beliefs and effectively manage sleep-disruptive rituals may all be useful

in managing the insomnia complaints of these patients.

Social Phobia

Social phobia is a fairly prevalent and, frequently debilitating condition charac-

terized by a markedly persistent fear and avoidance of one or more social situ-

ations involving exposure to unfamiliar people and/or evaluative scrutiny by

others (American Psychiatric Association, 1997). When those with social pho-

bia encounter a situation wherein they expect scrutiny and possible evaluation

by others, they experience extreme anxiety. In some cases, this anxiety may

culminate in panic characterized by extreme discomfort, palpitations, tremu-

lousness, blushing sweating, and pronounced fears of social rejection or nega-

tive evaluation by others. However, unlike the unpredictable, spontaneous panic

attacks that characterize panic disorder, those with social phobia recognize that

their panic symptoms are situation-specific and derive from their concerns

about scrutiny and negative appraisals (Stein & Mellman, 2005). Whereas those

with social phobia realize that their fears and beliefs about social scrutiny/

evaluation are unhelpful and often disproportionate to their actual social experi-

ences, they nonetheless remain symptomatic and attempt to avoid or minimize

contact with social situations that provoke their physiologic and cognitive

phobic symptoms.

Epidemiological studies suggest that between 3% and 13% of the general popu-

lation suffer from social phobia at some time during their lives (American

Psychiatric Association; Cairney et al., 2007; Grant et al., 2005). In clinical sam-

ples, prevalence rates are higher with reported rates ranging between 10 and 20%

(American Psychiatric Association, 1997) among outpatients with anxiety disor-

ders and up to 26% (Todaro, Shen, Raffa, Tilkemeier, & Niaura, 2007) among

inpatients with selected comorbid medical conditions. Individuals with social pho-

bia most often fear speaking in public or interacting with strangers. Less common

are fears of performing such activities as eating, drinking or writing in public. In a

subset of those with social phobia, social fears and avoidance pervade most routine

social situations and, in such cases, the term, generalized social phobia is typically

applied. Over time, social phobia places individuals at risk for considerable mor-

bidity including a reduced number and quality of social relationships, a reduced

likelihood of marriage, academic and vocational underachievement, disability, and

eventual onset of depression and other serious psychiatric conditions (American

Psychiatric Association, 1997; Beesdo et al., 2007; Stein & Mellman, 2005).

Self-medication with alcohol or other substances may give way to substance abuse/

Specific Phobias

43

dependence in a subset of those with this condition, particularly those with general

social phobia.

There is mixed evidence that social phobia confers some risk for the develop-

ment of insomnia. Stein, Kroft and Walker (1993), for example, compared the sleep

appraisals of patients with generalized social phobia and a matched group of

healthy controls using the Pittsburgh Sleep Quality Index, a measure with high

sensitivity and specificity for insomnia (Buysse, Reynolds, Monk, Berman, &

Kupfer, 1989). Comparisons showed that those with social phobia reported signifi-

cantly poorer sleep quality, longer latencies to sleep onset, more frequent nights

with sleep disturbance, and more pronounced daytime dysfunction that did the

controls. In contrast, PSG comparisons (Brown, Black, & Uhde, 1994; Papadimitriou

& Linkowski, 2005) have shown no differences between those with social phobia

and healthy controls on standard sleep measures of sleep onset latency, sleep effi-

ciency, REM latency, REM distribution, REM density, or other measures of sleep

architecture. Nonetheless, studies have shown that PSG is less prone to discriminate

normal sleepers from insomnia sufferers than are subjective measures such as self-

report questionnaires or data derived from subjective sleep diaries (Buysse, Ancoli-

Israel, Edinger, Lichstein, & Morin, 2006; Lineberger, Carney, Edinger, & Means,

2006). Hence, the subjective sleep complaints of those with social phobia should

not be underestimated.

As noted by Weissberg, (Weissberg, 2006) social phobia typically involves a

form of performance anxiety. It is noteworthy that when faced with the challenge

of sleeping, performance anxiety is thought to perpetuate psychophysiological

insomnia. Hence, it is possible that this inherent form of anxiety in the social pho-

bic enhances risk for sleep difficulties and should be considered a potential treat-

ment target, at least in some people. In other cases, sleep disturbance may be traced

to comorbid depression that evolves as a consequent of the phobic condition. Of

course, secondary sleep difficulties may emerge in those who abuse alcohol to cope

with social phobia. Given these possibilities, a thorough assessment of factors such

as sleep-related performance anxiety, comorbid mood disturbance, and substance

use patterns should be included in the evaluation of insomnia complaints in patients

who also suffer from social phobias. In turn, cognitive and behavioral therapies that

target performance anxiety and mood disturbance as well as specialized substance

abuse treatment programs may all be of some value in the management of social

phobia in those who present with insomnia complaints.

Specific Phobias

Specific phobia is a condition characterized by marked fear and avoidance of an

object or situation (American Psychiatric Association, 1997). For example, some-

one with a fear of flying may be able to avoid flying by taking ground transporta-

tion. If a situation necessitated air travel (e.g., a mandatory business trip to an

island), the Specific Phobia sufferer might be able to fly but only with intense anxiety

44

3 Anxiety Disorders and Accompanying Insomnia

and fear. The criteria for this disorder also stipulate that: (1) exposure to the feared

stimulus results in an immediate anxiety response; (2) the person realizes that the

fear is excessive/unreasonable; (3) the phobic situation/stimulus is avoided or

endured with intense anxiety/distress; (4) the phobia produces marked distress or

functional impairment; (5) and the anxiety/avoidance is not better accounted for by

another disorder (American Psychiatric Association, 1997). In adults, the duration

criterion is at least 6 months. As outlined by the DSM-IV-TR (American Psychiatric

Association, 1997), various types of specific phobia types exist including: (1)

Animal type (fear of animals or insects); (2) Natural Environment type (storms,

heights, water); (3) Blood-Injection-Injury type (fear of seeing or receiving an

injection, medical procedures etc.); (4) Situational type (fear of situations such as

riding in an elevator, enclosed spaces, etc.); and (5) Other (phobias that do not fall

into the aforementioned types). Prevalence rates for these Specific Phobias are

about 10% and approximately 12% lifetime (Kessler et al., 2005). Although not all

Specific Phobias have been the subject of treatment efficacy trials, available data

suggests that the most commonly occurring Specific Phobias are effectively treated

with Cognitive Behavior Therapy consisting of exposure and some form of cogni-

tive restructuring (Antony & Barlow, 2002).

Currently, studies concerning the relation between specific phobias and insomnia

or other forms of sleep disturbance are generally lacking. However, it is noteworthy

that claustrophobia has been shown to affect adherence to Continuous Positive

Airway Pressure treatment of sleep apnea (Edinger & Radtke, 1993) although admit-

tedly this difficulty is not specifically linked to insomnia. Nonetheless, these cases

of claustrophobic responses to CPAP treatment of sleep apnea are effectively treated

with the behavioral intervention, in-vivo exposure (Edinger & Radtke, 1993; Means

& Edinger, 2007). See Chap. 9 for a description of this treatment protocol.

Conceivably, some specific phobias could disrupt sleep. For example, a severe

case of arachnophobia could disrupt sleep if there was concern that spiders were in

the sleeping environment. Although we could not locate scientific accounts of adult

fear of the dark (scotophobia) and insomnia, it is not entirely uncommon to see this

problem clinically. In addition, there are some self-help interventions available on