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