10: PSYCHOLOGICAL DISORDERS [Rev 1-16-2019]
This is one of the general issues addressed in Step C
For psychotherapists, diagnosis of psychological issues tends to be automatic and continuous. We are less likely to begin with a focus on insomnia than other issues. At the same time, patients are far more likely to come to us for anxiety, depression, or interpersonal issues than for insomnia. For most therapists, insomnia is one issue in the treatment of psychological disorders. Here, we are reversing that order, to consider psychological disorders as possible issues in the treatment of insomnia.
Insomnia is a common symptom of many of our patients. We expect anxiety to keep a person from falling asleep and depression to cause a person to have disturbed sleep. We expect people with PTSD to have nightmares and awaken, and so on. The direction of causality is seemingly obvious: the psychological disorder is the reason for the patient’s insomnia. In making this assumption, we could be right much of the time. Especially when a person is in psychotherapy, it is natural to interpret insomnia as another symptom of the disorder we are already treating.
Reite, Weissberg and Ruddy provide a discussion (p. 202) and a table (Table 8-5) of other disorders that can lead to anxiety-like symptoms.
Rumble and Benca also provide a table (p. 127) of the sleep consequences of major psychological disorders and additional discussion of the effects of several disorders in the following pages.
These should be considered first, both because psychotherapy or medication for anxiety could be wasted on some people.
However, persistent loss of sleep can also be a source for the development of another psychological disorder. For example, a person who can’t sleep could be exhausted and appear depressed, or exhausted and unable to focus on work or school, then depressed or anxious about his/her poor performance. A person could have anxious thoughts because he/she can’t get to sleep.
Even when the main source of a person’s insomnia is a psychological disorder, other factors can exacerbate the problem (First and Tasman, 469), and treatment of those factors first may lead to more rapid relief than treatment of the primary psychological disorder alone.
Because of the complex inter-relatedness of insomnia and psychological disorders, Rumble and Benca (p. 128) recommend looking at a patient’s recent history of both issues together. If variations in psychological problems seem to lead to differences in sleep, focus on the patient’s psychological issues; if the reverse is true, focus on insomnia treatment.
When a patient is successfully treated for a psychological disorder, failure to address the person’s insomnia can lead to increased risk for relapse (Rumble and Benca, p. 132).
10a. Diagnosis
We can get some information about a person’s psychological diagnosis from reports of sleep disturbances, but it tends not to be definitive. In most cases, there can be more than one cause of a particular form of sleep disturbance.
However, if we have a psychological diagnosis for a patient, it may give some information about his/her sleep issues, and that can suggest treatments.
Sleep can easily be disrupted when a person is in stress, and many other psychological issues increase a person’s overall level of stress.
10b. Treatment
Treatment of a person’s psychological disorder may also treat the person’s insomnia. For example, treating anxiety with relaxation techniques may also provide the patient with an effective way to prepare for sleep.
Even in psychodynamic or interpersonal therapies, it may pay to combine some direct focus on sleep with the more general treatment of the person’s psychological issues. To the extent that a person’s psychological issues are exacerbated by sleep loss, a cognitive or behavioral focus on insomnia may partly alleviate other symptoms as well.
When medications are used in the treatment of psychological disorders, attention should be paid to their possible impact on the person’s sleep. For example, an energizing psychotropic medication, taken at bedtime, could interfere with sleep and thus exacerbate the patient’s symptoms (Section 36).
Treatment of the psychological disorder may be effective and the person continue to have problems with sleep. Continued insomnia can also be a risk factor for relapse of the psychological issue (Rumble and Benca, p. 126).
10c. More on Specific Psychological Disorders
The following specific connections to insomnia are included more as issues to watch for than as suggestions for modifying treatment for people with these issues. It is not unusual for patients to accommodate to some of their symptoms, expect them, and fail to report when they happen. For example, a therapist who knows that a patient has PTSD should remember to ask about sleep disturbances and difficulties falling asleep, then look for ways to treat that person’s insomnia in addition to the other PTSD symptoms.
ANXIETY
Anxiety is commonly associated with difficulty falling asleep (Morin, 37). The person holds back upsetting thoughts all day, and they return with the relaxation of defenses in preparation for sleep. Common symptoms of anxiety – racing heart, tight muscles, obsessive thinking, etc. – make drifting off into sleep difficult or impossible. When it comes, sleep may be shallower, lighter, and more prone to interruptions into consciousness.
A person with generalized anxiety disorder may have trouble falling asleep and staying asleep. They have reduced overall sleep time and are unrestored by sleep (Rumble and Benca, p.130). People with more focused fears may have more clearly limited episodes of insomnia, as their fears are triggered by events and fantasies.
An anxious person is already hyper-reactive to fears and threats. Sleep loss can increase the person’s reactivity, leading to even greater anxiety (Daitch,30). If a person has a sleep problem, anxiety can make it worse, first, by increasing the person’s tension level, and second by attaching to the idea of being unable to fall asleep. (Morin, 53, 69)
Anxiety can affect sleep in many ways, depending on the source and object of anxiety. It can lead a person to have more disrupted sleep when away from home, if new or strange places are seen as dangerous or if the person worries about things going badly at home in his/her absence..
Many physicians prescribe anxiety medications at bedtime to deal with this issue. However, medications have disadvantages (Section 36). Alternatives to medication are suggested in Section 44.
Reite, Weissberg and Ruddy (p.56) agree that an anxious person can get some relief from a benzodiazepine with sedative-hypnotic properties. On the other hand, Glovinsky and Spielman, (p.183) recommend treating anxiety throughout the day, rather than only at night. They also note that an anxious person can go to sleep easily for a few hours, when the need for deep, non-REM sleep is greatest. Then the person may awaken for various reasons, and be prevented by anxiety from returning to sleep at that time.
Difficulty about sleeping can lead to anxiety about sleeping. (Glovinsky and Spielman, 146). This can make it difficult to determine which to treat first. If the person’s main anxiety is about sleeping, perhaps one should treat the insomnia first. A good first approach is to suggest increases in the person’s exercise (Section 23).
PANIC
People who have panic attacks in their sleep typically have difficulty getting to sleep and maintaining sleep (Rumble and Benca, p.131). They may be anxious going to bed, in anticipation of awakening in panic, and when they are awakened by an attack, find it difficult to return to sleep.
DEPRESSION
While anxiety typically affects a person’s ability to get to sleep or get back to sleep, depression typically limits a person’s ability to stay asleep through the night (Morin, 63). Depression can also have affect falling asleep, early awakening, decreased amounts of sleep, and the restorative effectiveness of sleep (Rumble and Benca, p. 128).
When a patient is being treated for depression, concomitant improvement in the ability to sleep can improve the effectiveness of the therapy for depression (Rumble and Benca, p. 126).
A person’s depression can be exacerbated by many of the general issues that also have an impact on the ability to sleep, such as chronic pain (Section 6), life stress (Section 33), and lack of exercise (Section 23). Depressed people often don’t take very good care of themselves, because of lack of motivation and energy, leading to napping (Section32), not being sleepy at night (Section 46), and a downward spiral. All of these can be addressed in treatment.
POST-TRAUMATIC STRESS DISORDER
Insomnia is one of the many common symptoms of PTSD. Others include general hyperarousal,, re-experience of the trauma or traumas, numbing, longer time falling asleep, and many awakenings (Reite, Weissberg and Ruddy, 208). People with PTSD commonly awaken from nightmares in a state of panic and high arousal, which can make returning to sleep difficult and frightening.
OBSESSIVE-COMPULSIVE
The sleep issues of people with obsessive-compulsive diagnoses tend to be similar to people with major depression – less time sleeping, less deep sleep, and REM sleep earlier in the night (Reite, Weissberg and Ruddy, 203-208)
BIPOLAR DISORDERS
People with bipolar disorder are likely to have insomnia in the manic phase and hypersomnia in the depressive phase. (Morin, 37)
OTHERS
People with a variety of disorders (bipolar, schizophrenia, and some personality disorders may have disorganized life styles that lead to variable sleep times. As a consequence, the sleep they get may not be as restful and restorative as they need. It can be helpful for them to follow a relatively rigid sleep-wake schedule, both to ensure adequate sleep time and to help organize their lives (First and Tasman, 470).