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A Hard Day's Night: Coping with Sleep and Anxiety

After a long day, you often daydream about the delicious moment when you'll crawl into bed and quickly fall into a deep sleep. But once you're under the covers, you may find yourself being kept wide awake by anxieties that seem to rush into your brain all at once.

Anxiety is one of the most common causes of insomnia, and more than 19 million Americans suffer from an anxiety disorder. That means that stress and anxiety are likely to be responsible for the daytime drowsiness many Americans experience at the office or at school.

Below, Richard Ross, MD, a professor of psychiatry at the Philadelphia Veterans Affairs Medical Center, discusses strategies for coping with stress and anxiety so that you can get the sleep you need.

What is the impact of everyday stress on sleep?
When we're stressed there is a set of physiological responses that occur within us. If a human being or any organism is stressed, he or she wants to be able to cope with that stress, and it's important to be vigilant and aroused. Certain neurochemicals are released in our brain that can have a tremendous effect on our level of vigilance and arousal. The majority of time people are able to cope with everyday stressors, and they do not affect sleep. But if the stressor occurs right before you're trying to go to sleep, it's possible that the release of stress chemicals could affect our ability to fall asleep. Very severe stressors can lead to nightmares, which can lead to arousals from sleep.

How does your mental state affect sleep?
The teaching amongst psychiatrists has always been that depression is typically associated with middle-of-the-night awakening and early morning awakening, which is awakening before you want to get up to go to work or do whatever your daily activity is. On the other hand, it's often been taught that anxiety and anxiety disorders are more commonly associated with a difficulty in falling asleep and staying asleep.

What anxiety states can disturb sleep?
Generalized anxiety disorder is a common anxiety disorder characterized by exaggerated arousal. Generalized anxiety disorder can be manifested during sleep, particularly if a person with generalized anxiety disorder lies awake worrying when he should be sleeping.

Panic disorder is an interesting form of anxiety disorder. It's characterized most specifically by unanticipated, spontaneous attacks of severe anxiety. These attacks build to a crescendo in a very short period of time, and they can be associated with a variety of physiological and psychological difficulties. A person feels their heart rate going up; they sweat. Psychologically, a person may feel so anxious that he or she is concerned that she's going to die.

Does it ever happen that people fear sleep?
People can become afraid of going to sleep for a variety of reasons. There are times when people develop a concern that the room in which they're used to sleeping is no longer a good place to sleep. So they begin to associate the room with not being able to fall asleep, and then they become fearful of trying to go to sleep in that room because they know they can't. So a vicious cycle begins to develop.

People with post-traumatic stress disorder, who have been traumatized psychologically by some terrible event, can be very hypervigilant, very aware of the environment, and therefore actually uncomfortable about going to sleep in the nighttime.

How are anxiety disorders treated?
The treatment of anxiety disorders typically is either pharmacological or psychotherapeutic. In terms of the psychotherapy of anxiety disorders, there are many very effective treatments. There's a lot of evidence that what is termed cognitive behavioral therapy can be very useful. By cognitive behavioral, I mean gently challenging the ideas that a person has about sleep and his sleep disturbance.

For example, a person might have the idea that death could occur during sleep. A person might have read that heart attacks occur at a certain time during the night and might actually be afraid to go to sleep. A cognitive behavioral therapist could challenge that idea and educate the person.

There are many pharmacological treatments for the anxiety disorders. Currently, psychiatrists are likely to use drugs that were originally introduced as antidepressant drugs, but have since been appreciated for their anti-anxiety effects as well. Interestingly, though, sometimes the antidepressants can have as a side effect a kind of activation that can interfere with sleep. Oftentimes a psychiatrist will recommend that his patient take an antidepressant drug early in the day to avoid a possible activating effect that will interfere with sleep at night. And there are anti-anxiety medications such as clonazepam and alprazolam.

What are some strategies to help people sleep?
In general, it's very important to avoid stimulating behaviors before bedtime and to emphasize good sleep hygiene. These behaviors are going to vary from person to person but in general it means avoiding caffeine after five in the afternoon, and not just coffee but also tea and cola drinks. It means not smoking shortly before bedtime and not smoking when awakening because nicotine is a stimulant. It means not going to bed and lying awake in bed for a long time. Instead, it's better to get up after a short while, go to a different part of the house, do something relaxing and then try to go back to sleep.

You may find it very relaxing to have a phone conversation with a particular person before going to bed. That person might be able to provide some reassurance and help the sleeper feel calmer. On the other hand, it wouldn't be a good idea to have a phone conversation with someone with whom you're having a disagreement.

What medications can help with sleep problems associated with anxiety?
There are several pharmacological treatments for insomnia. In the past, psychiatrists typically used drugs of the benzodiazepine class, such as Valium and Librium, to help people with sleep. There's agreement among psychiatrists that in the short term that a benzodiazepine is useful. There isn't yet a consensus that long-term treatment with benzodiazepines is helpful.

There are newer medications that act a little bit differently from the old-time benzodiazepines, and some of the excitement about these newer drugs has to do with the fact that they seem to have a shorter duration of action. So you can get help with sleep, but then not feel very tired, hung over or drugged the next day.

Why do worries often surface at night?
The question of why worries often surface at night is an interesting one, and I have to say at the outset that I don't have the answer to that. In this modern day, when we're all trying to do so many things and balance so many activities in our lives, I think there's a tendency to use the bedroom as a place to accomplish things other than sleep. Historically, Freud and other psychoanalytic thinkers thought that there was something about dreaming that enabled a person to work out certain internal conflicts. So it's probably worth saying that it may be that conflicts are worked out at night in our sleep.