The National Institute of Mental Health estimates that one in five Americans have some sort of mental illness. The severity and duration can vary widely, and it is a much smaller percentage that is under medical treatment.
Sleep disorders are potential symptoms of almost every psychiatric illness. About 40% of patients who seek medical help for sleeping problems have a psychiatric condition. Meanwhile, to have a mental health disorder without sleep problems is quite rare: fewer than 20% of mental health patients don’t have sleep problems.
To an extent, sleep quality can be a barometer of mental health. For this reason, psychiatrists always inquire about sleep behavior when making a diagnosis.
Sleep disorders often coexist with anxiety and panic disorders, depression, ADHD, schizophrenia, and bipolar disorder. Problematically, the sleep issues associated with these mental health disorders make it more challenging to manage symptoms and experience the benefits of treatment.
The relationship between mental illness and sleep
Poor sleep is both a symptom and a cause of mental illness. Sleep problems may contribute to the development or prolongation of mental illness by making it more difficult to cope with mental problems.
Sleep disorders are comorbid with many other illnesses; the most common comorbidities with insomnia are mental illnesses. It’s estimated that 40% of insomnia patients and over 45% of hypersomnia patients have a psychiatric condition. On the other hand, people without mental illness have substantially lower rates of insomnia. It’s a striking enough difference that nobody doubts the tie between sleep disorders and mental illness any more.
When it comes to the sleep they do get, people with mental illness often report that it’s not restorative. They wake up still feeling tired, whether from waking frequently during the night, falling asleep too late, or waking too early. In fact, as we’ll go into in the sections below, many studies show that patients with mental health disorders experiences demonstrable changes to their sleep architecture. Often, the individual spends more time in the lighter, less restorative stages of sleep, and less time in the critically important deep and REM stages of sleep.
Insomniacs on the whole tend to suffer from this problem – getting less sleep overall and spending insufficient time in the deeper parts of sleep. This is what makes the disorder so particularly frustrating: they feel like there is no relief from their discomfort.
This lack of sleep in turn makes it more challenging to cope with the symptoms of their mental illness. The REM stage of sleep provides us with the emotional and cognitive benefits of sleep. With sufficient REM sleep, we feel emotionally balanced, and able to regulate our emotions and make good judgments. Our brain works and processes information as it should. Without it, we’re moodier, prone to irrationality and poor decision-making, and have difficulty remembering things. It’s easy to see how this mindset makes it tough to cope with mental health.
Together, mental illness and insomnia exacerbate the effects of each other, creating a classic negative feedback loop, and once they get started, push the patient in a downward spiral. This makes treatment of both conditions difficult.
Left untreated, the sleep problems associated with mental health disorders can be particularly dangerous. A University of Michigan study found a strong correlation between insomnia and suicide.
In the following sections, we’ll review the sleep disorders commonly associated with different mental health conditions.
Nearly one in five Americans suffers from some sort of anxiety disorder, such as generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder (OCD), phobia, post-traumatic stress disorder (PTSD), or panic disorder.
Sleep problems associated with anxiety disorders
Anxiety results from a reaction to stress. Big or small, stress of all kinds affect the nervous system. Individuals with an anxiety disorder, however, experience stress at a more acute level. It may stem from obsessive anxious thoughts, or they may be coping with PTSD from a trauma. Regardless of the cause of their stress, their nervous system does not “reset” back to normal as it does for those without an anxiety disorder.
This heightened state of anxiety keeps their nervous system constantly alert, in direct opposition to the sort of relaxation necessary for falling asleep. This experience occurs even at the hormonal level. Cortisol, the body’s stress hormone, operates in inverse to melatonin, the hormone responsible for inducing sleep. With more stress in our system, the tougher it is for our brain to produce adequate amounts of melatonin.
People with anxiety disorders may be prone to the following sleep problems:
- Insomnia, which describes difficulty falling or staying asleep. Many individuals with anxiety disorder suffer from all-consuming anxious thoughts, anticipatory anxiety toward potential phobia triggers, or sense of feeling generally overwhelmed. This level of anxiety makes it difficult to relax the mind before sleep.
- Hypersomnia, defined as oversleeping. Individuals may find themselves oversleeping as a response to the stress or exhaustion from insomnia. Insomnia and hypersomnia frequently occur together in many cases of anxiety disorders
- Nightmares are a common symptom of PTSD, where the individual relives the trauma during an intensely vivid dream.
- Nocturnal panic attacks are experienced by 44 to 71% of patients with panic disorder. These share symptoms with daytime panic attacks, except that they occur during non-REM sleep. The individual wakes up feeling extreme panic or fear, perhaps accompanied by sweats, pains in the chest, and increased heart rate.
Psychotherapy, particular cognitive behavioral therapy (CBT), is one of the most effective treatments for individuals experiencing sleep problems related to their anxiety disorder.
CBT is often recommended for anxiety disorders. CBT-I, the specialization devoted to insomnia, applies the same principles the patient is already familiar with from regular CBT, such as reframing their negative thoughts, to sleep. Therapists work with patients to educate them about healthy sleep habits, help them recognize the thoughts and behaviors interfering with their sleep, and learn how to replace them with healthier reactions.
Schizophrenia affects 1% of Americans. This severe mental illness interferes with their ability to process reality, manage their emotions, and communicate with others. It’s accompanied by debilitating symptoms, such as hallucinations and psychosis.
Sleep problems associated with schizophrenia
Between 30 to 80% of people with schizophrenia experience disturbed sleep.
Sleep problems common to schizophrenia include:
- Abnormal or irregular sleep patterns. Individuals with schizophrenia don’t tend to sleep for one extended period overnight; instead, they are more prone to sleep at any point during the day or night. Based on their research of mice with defects in the SNAP25 gene (which is known to be linked to schizophrenia), scientists hypothesize the irregular sleep patterns are caused by a delayed melatonin release and shifted circadian rhythm. For individuals with schizophrenia, the delayed melatonin release continues pushing their sleep onset back later and later into the night, until eventually there is no clear circadian rhythm at all.
- Inconsistent sleep volume. In addition to sleeping at irregular hours, people with schizophrenia generally tend to not get a regular amount of sleep on a day to day basis. At times they are prone to insomnia, and at others prone to hypersomnia. The side effects of their medication, or the symptoms of the disorder such as hallucinations, can cause either extreme. Because their sleep is so irregular, both in onset and in volume, their sleep quality also tends to be low. As a result, they’re less well-rested and prepared to cope with the symptoms of their disorder.
The first generation of antipsychotics used to treat schizophrenia had no universal effect on sleep architecture, but the later generation of so-called atypical antipsychotics, including clozapine, olanzapine, and quetiapine, have observable positive effects on sleep. Schizophrenic patients who take them sleep longer. Some drugs increase the length of their slow-wave sleep, while some increase REM latency, similar to the effect of SSRI drugs on people with depression.
Treating the sleep issues does tend to alleviate the intensity of the psychotic symptoms of schizophrenia. However, clinicians advise adjusting the CBT-I strategies to account for the potentiality of triggering psychosis:
Sleep problems associated with bipolar disorder
The sleep issues a person with bipolar disorder experiences will change depending on whether they are in a state of mania or depression.
The most common sleep problems affecting individuals with bipolar disorder include:
- Insomnia, or difficulty falling or stay asleep. Insomnia can occur during both mania or depression.
- Sleeplessness is more common with episodes of mania. Distinct from insomnia, this describes the ability to go for long periods without sleeping, and without feeling a subjective need for sleep.
- Hypersomnia, or oversleeping, is more common during episodes of depression.
- Irregular sleep patterns are common, especially during episodes.
- Delayed sleep phase syndrome (DSPS) describes a condition where the individual’s circadian rhythm is delayed. The person naturally tires at a later time than “normal,” so they fall asleep and wake up later, causing disruptions and tiredness during their daily routine as they adhere to the “normal” schedule of daily life. DSPS is like living in a constant state of jet lag.
- Sleep apnea is significantly more common among individuals with bipolar disorder. The sleep-disordered breathing caused by sleep apnea disrupts their sleep, which can spark another manic episode or make it more difficult to cope during periods of depression.Whether caused by or independent of bipolar disorder, the sleep problems these individuals experience make it more difficult to cope with the symptoms of the disorder. The highs and sleeplessness associated with mania catch up with the individual during the resulting depression stage, during they worsen the overall hopelessness they feel.Meanwhile, lack of sleep prior to an episode of mania is one of the biggest warning signs that mania is about to occur. Even sleep deprivation from something as benign as jet lag can trigger an episode.
Even in between episodes, individuals with bipolar disorder also experience lower quality sleep. They have more difficulties falling asleep and experience more interruptions to their sleep.
As with most cases of insomnia, research indicates CBT-I is an effective behavioral treatment for insomnia among individuals with bipolar disorder. Sleep restriction and stimulus control techniques in particular proved effective.
- https://www.tuck.com/mental-illness-and-sleep/ LAST UPDATED JUNE 12, 2018