Insomnia and Anxiety (Series in Anxiety and Related Disorders) by Jack D. Edinger Colleen E. Carney Page A
Authors: Jack D. Edinger Colleen E. Carney
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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
42
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
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
42
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
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