Treatment of Insomnia in Anxiety Disorders

Insomnia is highly prevalent in psychiatric disorders, and it has significant implications. This review focuses on insomnia in the context of anxiety disorders. The prevalence of comorbid insomnia in anxiety disorders is addressed and the clinical implications associated with insomnia are discussed as well as when and how to treat this important comorbidity. Just how specifically insomnia relates to and possibly affects anxiety disorders is highlighted by the fact that insomnia is one of the defining criteria in a number of the DSM-IV-TR anxiety disorders. For example, difficulty in falling or staying asleep is a criterion for PTSD, acute stress disorder, and generalized anxiety disorder (GAD). The relationship of insomnia to anxiety disorders is also influenced by comorbid major depression. The severity of insomnia is increased when an anxiety disorder is comorbid with a major depressive disorder (MDD).1 This is highly relevant because 58% of MDD patients have a lifetime anxiety disorder.2 The presence of insomnia has a deleterious effect on daytime functioning and negative effects on quality of life, including social and work relationships.3 Also, there is clear evidence that the presence of insomnia in anxiety disorders is associated with increased morbidity. For example, in patients with PTSD, insomnia is associated with an increased likelihood of suicidal behavior, depression, and substance abuse as well as nonresponsiveness to treatment.4-6 In addition, insomnia as an early symptom in traumatized patients increases the risk of the development of PTSD 1 year later.7 Early assessment It is important to carefully assess for insomnia early in the evaluation of patients with anxiety disorders and to aggressively treat this complicating comorbidity. Insomnia is an underrecognized and undertreated problem. Patients rarely report their symptoms of insomnia spontaneously to their doctor. Adding to the problem of detecting insomnia is the finding that doctors rarely inquire about insomnia in their patients.3,8,9 Thus, a carefully taken history is an important first step in the assessment of insomnia. Self-rating sleep questionnaires and direct clinical interviews are used to obtain a history of potential sleep disorders (eg, insomnia). A number of well-validated sleep questionnaires have been widely used. The most widely used and validated questionnaire is the 19-question Pittsburg Sleep Quality