Heidi Moawad, MD

Pain has a substantial impact on sleep, and an insufficient amount of restful sleep can increase pain susceptibility. Brief bouts of pain—such as pain due to a traumatic injury or a short-lived medical issue—can cause almost immediate adverse effects on daytime functioning and alertness. The symptoms can begin to manifest as soon as the day after a night of inadequate sleep. Chronic pain can lead to prolonged sleep deprivation that can have physical, emotional, and behavioral complications. For example, in the rheumatologic literature, it has long been noted that there is an association between chronic musculoskeletal pain, sleep disruption, and depression.

 More recent research attempts to elucidate the contributing factors and address treatment planning.

 is a benefit of effective pain management. A pain management strategy may also require dedicated attention to sleep quality and sleep quantity. Evaluation of sleep disturbances in the context of chronic pain requires a comprehensive assessment of subjective symptoms and objective tests, such as sleep questionnaires and an 

. Treatment of sleep issues caused by chronic pain is individualized and multifaceted and must take the chronic pain condition, the specific sleep disturbance, and the psychiatric sequalae into account.

Sleep disturbances caused by chronic pain

It is estimated that between 50% to 80% of those living with chronic pain experience sleep disruption. For example, a study revealed 53% of participants with chronic pain met criteria for insomnia, while only 3% of the pain-free controls met the criteria.

 There is also a potential a dose-response link between the intensity of pain and its impact on sleep.

Insomnia is the most commonly noted sleep disorder associated with chronic pain. A large meta-analysis noted a high prevalence of other sleep disruptions as well, with the 3 most common being insomnia at 72%, restless leg syndrome with a prevalence of 32%, and obstructive sleep apnea with a prevalence of 32%.

 It is notable that the 3 most commonly observed sleep disorders added up to greater than 100%, underscoring the fact that chronic pain can be associated with more than 1 type of sleep disturbance at a time (

There are several mechanisms by which pain interferes with sleep. Pain is an obvious distraction that makes it hard to fall asleep and can lead to waking up at night, especially when pain medication wears off. However, pain also interferes with the physiology of sleep in targeted ways that go beyond the conscious distraction caused by the discomfort. There is a variability in chronic pain diagnoses, and the distinctive types of pain syndromes affect sleep differently. Furthermore, the impact of chronic pain on sleep appears to be multidimensional. Research into various pain syndromes and their physiological impact on sleep provide a range of insights into the ways that pain interferes with sleep.

For example, acute post-surgical pain also has quantifiable effects on sleep, including a measurable decrease in the time spent in the 

 (REM) of sleep. Changes are noted not only after general anesthesia, but also after regional anesthesia.

 This observation suggests that the pain itself (rather than the general anesthetic wearing off) is at least a contributing factor to post-operative pain-associated sleep disturbances.

Fibromyalgia is frequently associated with sleep disturbances.

 Patients with fibromyalgia have reduced short-wave sleep and abnormal α-rhythms, with episodes of wakefulness during non-REM sleep.

 Daytime fatigue and non-restorative sleep are common complaints among patients who have fibromyalgia, and these polysomnogram findings are consistent with inadequate sleep quality, even when patients might seem to have slept for an adequate number of hours.

Neuropathic pain is also associated with sleep disturbances, and there is a strong bidirectional relationship between sleep disturbances and neuropathic features of pain.

Sleep disturbances are common among patients who have chronic, recurrent headaches. Common headache types, including tension headaches and migraines, often have associated symptoms besides pain, including sleep disturbances.

 As with fibromyalgia, the amount of time spent sleeping is not necessarily diminished in patients who have headache-associated sleep disturbances. Instead, it is the restorative effects of sleep that are impacted by chronic headache pain, rather than the total amount of sleep per night. The features of sleep disturbances can also vary with different types of headaches.

Sleep disturbance also can affect a person’s response to pain. As sleep stages are compromised, daytime pain increases through a process of hyperalgesia, in which lower pain stimuli result in higher pain perception and greater pain-associated impairment than would be expected otherwise.

According to research in patients with fibromyalgia, sleep deprivation impairs pain-inhibition pathways that normally help control pain.

 Studies also suggest that sleep deprivation can lead to systemic inflammation that can amplify pain.

 The evidence does not suggest that sleep deprivation can independently cause pain; rather, sleep deprivation may amplify the perception of pain that is already occurring as a result of underlying causes.

It is important to note that, while there is a strong association between sleep disorders and chronic pain and mood disorders, it is very difficult to determine which of these has a stronger impact on the others.

Psychiatric consequences of pain-related sleep disturbances

A number of psychiatric sequelae can complicate pain-induced sleep disturbances. There is a strong relationship between chronic pain that is associated with sleep disturbances and subsequent diagnoses of depression and anxiety.

 Other psychiatric issues, such as delusions, hallucinations, or mania are not commonly noted with pain-induced sleep disturbances.

Studies looking at neuropathic pain suggest that inflammation may be associated with psychiatric changes and behavioral alterations.

 However, experts are not completely sure whether there may be other contributory factors as well, and future research regarding the etiology of psychiatric disturbances in pain-induced sleep disturbances may answer some of the currently unanswered questions about these complex relationships.

Regardless of the exact molecular cause, psychiatric diagnoses of anxiety or depression can cause severe patient distress and may also lead to behavioral changes. These issues must be addressed in the clinical setting so that patients can have access to symptom relief and an improved quality of life.

Because of the bidirectional relationship between pain and sleep disturbances, experts recommend evaluating patients who have chronic pain for undiagnosed sleep disorders.

 Evaluation can include commonly used sleep questionnaires, such as the Mini Sleep Questionnaire (MSQ), the Pittsburgh Sleep Quality Index (PSQI), and the Epworth Sleepiness Scale. Objective measures include polysomnogram, Multiple Sleep Latency Test (MSLT), and Maintenance of Wakefulness Test (MWT). Additionally, screening tests for depression and anxiety are often necessary as well. Key components of the evaluation include diagnosing the sequelae of pain in addition to diagnosing the pain syndrome.

The treatment of pain has far reaching effects beyond pain control. Yet, managing pain-related sleep disturbance is not based on pain management alone. Interventions directly aimed at treating sleep disturbance are associated with a better outcome than interventions aimed at only treating the pain.

Currently, very little research has been done on the optimal treatment of sleep disorders in patients with chronic pain, and there is a lack of formal guidelines for approaching the problem. Research is emerging, however, and some experts recommend tailoring sleep care to the specific patient, rather than using a general approach to managing sleep disturbances for patients in whom chronic pain is believed to be the cause of the sleep problem.

 Some authors even suggest that chronic pain is a triad that includes pain, sleep disturbance, and depression.

There are a number of different treatment approaches for pain-associated sleep disturbances, including cognitive behavioral therapy, medication, and respiratory support during sleep for patients who need it.

 Treatment of chronic pain should always take sleep issues into consideration. Opioids, for instance, can alter sleep architecture, and while there are many disadvantages to long-term use of opioids for treating chronic pain, there are rare situations in which they are prescribed. This treatment can be especially problematic for patients who have respiratory sleep disorders, like sleep apnea. Given the complicated balance involved in chronic pain management, opioids might still be an appropriate part of the treatment plan for certain patients who have respiratory side effects. In these cases, the use of respiratory assistance, such as continuous positive airways pressure (CPAP) during sleep, may be an effective solution.

The overall approach to pain management that is complicated by sleep and psychiatric issues requires a tailored plan. It might or might not involve treatments for more than 1 diagnosis of the pain/sleep disturbance/depression triad. For instance, antidepressants might help with pain control and with mood stabilization. And anticonvulsants may help with pain control while also improving sleep.

 But, despite these obvious potential overlaps in treatment, some patients might benefit from optimal treatment approaches tailored to each diagnosis, even if completely separate treatments for each condition are required to achieve control of symptoms. Pharmacological interventions often must be selected based on the targeted symptoms. Even conservative management approaches, such as counseling, cognitive behavioral therapy, and physical therapy are most effective when they are symptom-specific, because the conservative approaches for treating each condition are not identical.

is Associate Editor Humanities in Neurology, Clinical Assistant Professor Case Western Reserve University School of Medicine, Div. of Medical Education, and Editor in Chief Emeritus of 

This article was originally posted on September 21, 2020, and has since been updated. Scroll down for the 

 of the full print issue in which it appeared. -Ed

1. Moldofsky H. The significance of the sleeping-waking brain for the understanding of widespread musculoskeletal pain and fatigue in fibromyalgia syndrome and allied syndromes. 

2. Cheatle MD, Foster S, Pinkett A, et al. Assessing and Managing Sleep Disturbance in Patients with Chronic Pain. 

3. Mathias JL, Cant ML, Burke ALJ. Sleep disturbances and sleep disorders in adults living with chronic pain: a meta-analysis. 

4. Dette F, Cassel W, Urban F, et al. Occurrence of rapid eye movement sleep deprivation after surgery under regional anesthesia. 

5. Choy EH. The role of sleep in pain and fibromyalgia. 

6. Stocks J, Tang NK, Walsh DA, et al. Bidirectional association between disturbed sleep and neuropathic pain symptoms: a prospective cohort study in post-total joint replacement participants. 

7. Fernández-de-Las-Peñas C, Fernández-Muñoz JJ, Palacios-Ceña M, et al. Sleep disturbances in tension-type headache and migraine. 

8. Kundermann B, Krieg JC, Schreiber W, Lautenbacher S. The effect of sleep deprivation on pain. 

9. Marshansky S, Mayer P, Rizzo D, Baltzan M, Denis R, Lavigne GJ. Sleep, chronic pain, and opioid risk for apnea. 

Prog Neuropsychopharmacol Biol Psychiatry

10. Nicholson B, Verma S. Comorbidities in chronic neuropathic pain. 

11. Nijs J, Mairesse O, Neu D, et al. Sleep disturbances in chronic pain: neurobiology, assessment, and treatment in physical therapist practice. 

Articles

Sleep disturbance and chronic pain work together to cause misery for patients, with one exacerbating the other. Here: Tips to address both and bring peace to patients.

Sleep Disturbances as a Sequalae of Chronic Pain 

is Associate Editor Humanities in Neurology, Clinical Assistant Professor Case Western Reserve University School of Medicine, Div. of Medical Education, and Editor in Chief Emeritus of

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Primary insomnia is a decreased ability to fall asleep and/or stay asleep, with resulting daytime effects of sleep deprivation, such as fatigue, dozing off, and irritability. The sleep problems of primary insomnia are not associated with lifestyle habits or a medical or psychiatric cause. Primary insomnia is diagnosed using DSM-5 and the International Classification of Sleep Disorders, 3rd Edition (ICSD-III) classification 

 Primary insomnia is a type of chronic insomnia as defined by the ICSD-III, and it tends to persist or recur for many years throughout a person’s life, often beginning during childhood.

This type of insomnia is usually idiopathic, although it can be impacted by mild to moderate stress. Primary idiopathic insomnia occurs without any identifiable cause and in the absence of anxiety. And people who have a history of primary insomnia may also have episodes of sleep state misperception (SSM), also known as paradoxical insomnia. With paradoxical insomnia, a person feels that they are experiencing insomnia, although they are getting enough sleep and don’t experience daytime signs of sleep deprivation. SSM is believed to affect 9% to 50% of the adult population, and it is 

 among people who also have bouts of primary insomnia.

Primary insomnia has 3 subtypes: idiopathic, stress-related, and SSM. Idiopathic insomnia is truly without any identifiable contributory factor, while stress-related insomnia can be characterized by mild stress, such as rumination or other thoughts throughout the night. Someone who has had episodes of idiopathic insomniacan also experience worsening symptoms when dealing with mild stress or can experience SSM during phases of adequate sleep.

The frequency of sleep symptoms can vary—primary insomnia can occur occasionally or frequently, and it can affect someone for just 1 night at a time or for many nights in a row. An individual affected by the condition can have trouble sleeping, may toss and turn in bed, or may get up from bed at night. Symptoms can also include 1 or more episodes of waking up during the night, often for less than an hour in total. People who have primary insomnia may be very concerned about the causes and effects of not getting enough sleep, and anxiety about sleep can exacerbate the insomnia.

A diagnostic work-up of insomnia includes a medical history, physical examination, and diagnostic tests. Daytime symptoms can include restlessness, feeling tired, falling asleep easily during waking hours, trouble concentrating, moodiness, and sadness. These symptoms are not usually present in SSM. A sleep study may show delayed sleep latency, sleep fragmentation, decreased sleep efficiency, and 

total sleep time in patients who have idiopathic primary insomnia.

 A sleep study would not be expected to show any abnormalities in SSM.

Treatments for primary insomnia include lifestyle modification, therapy, and prescription medications. Non-medical therapies include counseling, cognitive behavioral therapy, biofeedback, avoiding naps or inconsistencies in sleep schedule, managing caffeine and alcohol intake, and avoiding stimulation from factors like bright lights before sleep.

 Medications commonly used for the treatment of primary insomnia 

benzodiazepines, antihistamines, and melatonin

A 42-year-old woman complains that she isn’t sleeping well at night. Although she is in good health, she reports that she has had trouble falling asleep for as long as she can remember. She recalls being tired in the mornings when she was a child, during her teenage years, and throughout her adult years. This is not related to stress, as she says she had always been even tempered and ambitious, and she isn’t prone to anxiety.

Her current sleep pattern is that she tosses and turns for hours before falling asleep, sometimes wakes up during the night around 4 AM, and generally falls back asleep until her alarm clock wakes her at 6:30 AM. At home, sounds of rain or cars outside wake her from sleep. And when she stays in a hotel, the sound of other people talking or shutting doors wakes her up.

She is a chemist and works full time as a vice president at a manufacturing company. She has a regular 8 to 5 schedule, working from home several days per week for the past several years. This practice is consistent with her company culture because most of the work involves communicating electronically. She says that sometimes she gets very tired during the day, but she works through the fatigue because she does not want to prolong her workday.

She then prepares dinner for her children and husband. After dinner, she usually takes a walk or exercises and later watches television with her family. She has a daughter who is attending college abroad for the year, and two kids in high school. The family often calls their college student daughter in the evening. The patient generally goes to bed around 11 PM after picking up around the house. Overall, although she is busy, she says she doesn’t have anything especially stressful going on in her life.

The patient is having an evaluation of insomnia at the urging of her daughter, who is studying pre-health classes in college. The main concern that she expresses is whether her insomnia could be caused by a health problem or whether she could be at risk of developing chronic health issues due to lack of sleep.

The patient’s physical examination was normal. She had a complete blood count and electrolyte blood levels that were normal. She had a home sleep study, which showed diminished sleep quality and delayed sleep latency, without evidence of issues like sleep apnea. She was presumptively diagnosed with primary insomnia, which was considered to be idiopathic.

She was offered the option of taking medication for her insomnia. She instead asked about whether there are any natural therapies, such as herbs, that she could take. In fact, there have been studies suggesting that herbal treatment may have an effect on insomnia. In one 

evaluating 50 patients, use of oil extracts for 8 weeks was associated with a reduction in scores on the Insomnia Severity Index (ISI) and the Pittsburgh Sleep Quality Index (PSQI).

 However, one challenge with using herbal remedies for treatment of insomnia is that there isn’t a consistent protocol or safety and efficacy profile when it comes to the products. In fact, very 

The challenge of using herbal remedies for treatment of insomnia is that there is no consistent protocol or safety and efficacy profile when it comes to the products. 

Her doctor suggested that she begin with lifestyle strategies that include avoiding looking at electronic devices for several hours before sleep, avoiding caffeine after noon, and adopting a more consistent exercise schedule. After a month, she did not experience improvement of her symptoms and asked to try prescription medication. Her doctor gave her a prescription for temazepam. After 1 month, she was pleased with the results, but she was concerned about the potential for addiction, so she asked if she could switch to melatonin. Her doctor gave her a schedule to taper the prescription and wanted to reevaluate the situation before starting the patient on another medication. After she discontinued the medication, the patient felt she was still getting better quality sleep and felt less tired during the day. The decision was made to hold off on any new medications as long as her symptoms were not troublesome.

• Patients who have primary insomnia might be concerned about medical causes of insomnia. Often, ruling out underlying causes can be a great relief for patients.

• Herbal treatments and alternative therapies may be beneficial in the management of primary insomnia, but doses and adverse effects are not well established.

• Treatment of chronic insomnia can be more effective when the patient is given several treatment options and has a voice in the plan.

• Sometimes temporary treatment can be effective for a bout of chronic primary insomnia that’s idiopathic.

 is Adjunct Professor at John Carroll University, and Instructor, Case Western Reserve University in Cleveland, OH. She is the editor in chief emeritus of 

1. Momin RR, Ketvertis K. Primary Insomnia. 

 Treasure Island (FL): StatPearls Publishing; 2020. 

https://www.ncbi.nlm.nih.gov/books/NBK554516/

2. Martucci M, Conte M, Ostan R. Both objective and paradoxical insomnia elicit a stress response involving mitokine production. 

https://pubmed.ncbi.nlm.nih.gov/32420904/

3. Melo DLM, Carvalho LBC, Prado LBF, Prado GF. Biofeedback Therapies for Chronic Insomnia: A Systematic Review. 

https://pubmed.ncbi.nlm.nih.gov/31123938/

4. Taherzadeh Z, Khaluyan H, IranshahyM. Evaluation of sedative effects of an intranasal dosage form containing saffron, lettuce seeds and sweet violet in primary chronic insomnia: A randomized, double-dummy, double-blind placebo controlled clinical trial. 

https://pubmed.ncbi.nlm.nih.gov/32736046/

5. Akram M, Daniyal M, Munir N, et al. Medicinal Plants Combating Against Insomnia: A Green Anti-Insomnia Approach. 

https://pubmed.ncbi.nlm.nih.gov/31663928/

When provided with an array of treatment options, patients tend to feel a sense of ownership by playing a role in their care. 

Primary Insomnia: A Lifelong Problem

Lucid dreams are both voluntary and involuntary events. What this means is that a person is aware that they are dreaming during a lucid dream. It can occur spontaneously, typically during REM 

. People experience lucid dreams only rarely, and they aren't typically distressing.

This type of dream has also been promoted as a means of self-reflection and problem solving. Proponents of the technique suggest that lucid dreams are a type of 

, in which a person could potentially reach another state of awareness to achieve greater insight than during the full waking state. The safety of this technique hasn't been established, however, in terms of psychological well-being or restorative sleep. And the idea of using lucid dreaming as a problem-solving method is not supported by the medical community.

There is more to dreaming than meets the (shut) eye.

Lucid Dreams: Many Questions Remain

Shift work sleep disorder is characterized by insomnia and excessive sleepiness lasting for at least 3 months in association with fluctuating work schedules. Patients who have this disorder experience an overall decreased amount of sleep. As defined by the 

International Classification of Sleep Disorders

, the condition also known as circadian rhythm sleep-wake disorder, shift work type or circadian rhythm sleep disorder (in DSM-5) is estimated to affect 

Because the inherent circadian rhythm is largely regulated by the 24-hour light/dark cycle, people who work overnight generally feel sleepier at night than during the day, even when they are at work or have slept during the day. Patients who work schedules with some or all shifts during the night when they would otherwise be sleeping may consequently experience disruptions in their circadian rhythm. These disruptions affect one’s ability to get adequate sleep, even when they have enough time to sleep. Most people who have shift work sleep disorder have 

Sleep disruption is also associated with behavioral manifestations of mood changes, such as irritability and social withdrawal. In addition to fatigue as a contributing factor, when mood changes like depression and anxiety are associated with shift work sleep disorder, they are thought to be caused by molecular alterations linked to circadian rhythm disruption. Research 

that the circadian clock is likely to regulate monoaminergic signaling, which mediates changes in dopamine, serotonin, and noradrenaline levels throughout the day.

 A disturbance in the circadian rhythm causes deregulation of these hormones at the level of molecular transcription, and this may result in symptomatic mood alterations.

Many shift workers are unable to adjust their circadian rhythm to their altered sleep wake schedules. This is evidenced by samples of salivary melatonin concentration, which normally 

 The diagnosis of shift work sleep disorder is a clinical diagnosis based on a patient’s medical history. The combination of insomnia, excessive sleepiness during waking hours, lack of sleep, and chronic shift work that is inconsistent with a regular day/night wake/sleep schedule leads to the diagnosis. Research 

that between 10% to 30% of shift workers fit the criteria for shift work sleep disorder, and it unclear why some shift workers are more prone to the condition than others.

Many pharmacological treatment strategies have been used to treat this acquired sleep disorder, including melatonin, zopiclone, lormetazepam, and modafinil. For example, one 

that was fairly representative of the effects of medications on the condition showed that pharmacological therapies increased sleepiness in some patients but did not improve overall sleep for the majority of patients.

 Non-pharmacological interventions include sleep education, use of bright light, napping, and physical exercise. These 

also have not been consistently effective.

A 47-year-old man has trouble falling asleep and reports not getting enough sleep throughout the night. He says he has no energy to do anything other than work and sit around at home.

His wife and daughter have accompanied him to the office visit. They explain that his moodiness has gotten worse over the past year. They say that he is irritable and sometimes seems down and uninterested in talking with them at home.

The patient works rotating shifts in a factory and has had the same job and schedule for about 5 years. He works 10-hour shifts with a schedule that varies weekly. He is scheduled to work from 10 PM to 8 AM on any 4 days of 1 week, followed by a week of working any 4 days from 10 AM to 8 PM. When an extra shift opens up with bonus pay, he takes it. He has often come home and gone back to work within 6 hours for an additional 10-hour shift when he can fit it in, which happens approximately 3 times per month.

The patient often tosses and turns in bed for hours before falling asleep, and sometimes he only gets a few hours of sleep before his next shift. He has not established a consistent sleeping pattern. He and his wife have installed heavy curtains with full window coverage to made sure their bedroom is completely dark during the daytime.

He agrees with his wife and daughter that he is quiet sometimes and irritable at others, but his family says these issues are getting progressively worse and he is very difficult to be around. The patient says he isn’t sad or anxious; instead, he is just tired and “zoned out.”

He gets enough to eat, and his wife is very attentive to planning healthy meals at home and packs healthy meals for him on his works days. He drinks 2 cans of caffeinated cold beverages at the beginning of every shift, and he doesn’t consume caffeine at any other time.

The patient smoked 1 pack of cigarettes per day since his 20s, but he quit about 5 years ago when a friend was diagnosed with lung cancer. He does not have any medical problems, and he isn't stressed at work or home. His physical examination is completely normal.

This patient was preliminarily diagnosed with shift work sleep disorder on his first visit. He and his wife agreed to keep a sleep diary over the course of 1 month. When they returned, they discussed the diary, which showed he had a very inconsistent sleeping schedule. He often came home and went to bed right away after a day or night shift, and sometimes he delayed going to bed for 3 to 7 hours after a day or an evening shift.

While shift work sleep disorder can cause diminished attention and increase the risk of accidents,

 this did not seem to be a problem for him. However, because he did not directly deal with equipment and rarely drove anywhere except work, he had limited opportunities to get into an inattention-induced accident.

The patient said that he did not want to look for a different job, as his pay rate and benefits were the best he had ever had in his life. He was advised to try to regulate his sleep schedule by going to bed at the same time every day during his week of night work and at the same time every day during his week of daytime work. He also wanted to try melatonin.

After several months, he was able to regulate his sleep on the weeks of his daytime shifts, but he still had an inconsistent sleep schedule on his week of nighttime work because he did not want to sleep during the day on his 3 days off. He continued to accept extra shifts whenever possible. He believed the melatonin helped him fall asleep and he felt that he was getting more rest on the days when he took it.

Overall, he did not have more energy, but he tried to be less irritable. His wife and daughter agreed he was more pleasant, yet still not very interactive. The family felt satisfied that learning about the disorder helped all of them cope with its clinical effects. They also all agreed the patient would aim eventually to get a job with a more regular schedule if he could find one without having to take a pay cut.

• Some people are more susceptible to shift work sleep disorder than others, and the reasons for this predisposition are unclear.

• Shift work sleep disorder is extremely difficult to overcome with medication. Because some patients’ symptoms improve with medication, it may be worth trying for those who can’t change their work schedule.

• Alternative therapies have shown limited success in the management of shift work sleep disorder. Nevertheless, sleep education can help patients and families cope and may serve as a motivation to eventually change circumstances when possible.

is Adjunct Professor at John Carroll University, and Instructor, Case Western Reserve University in Cleveland, OH. She is the Editor in Chief Emeritus of 

1. Boivin DB, Boudreau P. Impacts of shift work on sleep and circadian rhythms. 

https://pubmed.ncbi.nlm.nih.gov/25246026/

2. Gumenyuk V, Roth T, Drake CL. Circadian phase, sleepiness, and light exposure assessment in night workers with and without shift work disorder. 

https://pubmed.ncbi.nlm.nih.gov/22823876/

3. Albrecht U. Molecular Mechanisms in Mood Regulation Involving the Circadian Clock. 

https://pubmed.ncbi.nlm.nih.gov/28223962/

4. Liira J, Verbeek JS, Costa G, et al. Pharmacological interventions for sleepiness and sleep disturbances caused by shift work. 

https://pubmed.ncbi.nlm.nih.gov/25113164/

5. Slanger TE, Gross JV, Pinger A, et al. Person-directed, non-pharmacological interventions for sleepiness at work and sleep disturbances caused by shift work. 

https://pubmed.ncbi.nlm.nih.gov/27549931/

A case of a patient with difficult-to-treat insomnia highlights the pervasive daytime effects of this condition.

Insomnia Associated With Shift Work Sleep Disorder

Insomnia is characterized by difficulty falling asleep, trouble staying asleep, and/or early waking. The result is usually inadequate sleep, with daytime effects associated with sleep deprivation. Up to 50% of adults 

they have experienced insomnia at some point in their life.

While not as common as insomnia, anxiety and depression are also fairly prevalent among adults. 

 surveyed a random sample of 3406 participants ranging from aged 18 to 79 years. Of the participants, 13.9% (10.0% men, 17.0% women) reported they had received a diagnosis of anxiety; 6.4% (5.5% of men, 7.1% of women) had received a diagnosis of depression; 28.6% (23.5% of men, 32.7% of women) reported a diagnosis of insomnia; and 14% reported self-perceived stress.

Anxiety and stress are closely linked, and they are among the chief causes of insomnia. The exact prevalence of stress and/or anxiety among persons with insomnia is unknown, but stress and anxiety have an 

 because of a variety of emotional and physical factors.

 As with insomnia due caused by other factors, sleep deprivation due to anxiety-associated insomnia can bring about a variety of distressing symptoms during the day. Fatigue, irritability, anxiety, and depression are common consequences of sleep deprivation of any cause. Health problems like weight gain, hyperglycemia, and elevated lipid levels are associated with chronic sleep deprivation as well.

A 61-year-old man complains of insomnia, with difficulty falling asleep, frequent waking throughout the night, and early morning awakening. He estimates this has been going on for at least 6 months to a year, but he reports it is getting worse. He has been having trouble sleeping every night for the past few months and he naps during the weekend and in the evenings after work. He notes that he feels tired throughout the day and drinks cold caffeinated beverages “all the time,” to stay awake, totaling about 6 standard 8 oz cans per day.

He has gained 35 pounds in the past year. He used to regularly ride his bike for about 20 miles 3 or 4 times per week, but he stopped because of a stressful situation at work that has been distracting him. 

For the past 2 years, he has been embroiled in a lawsuit related to an accidental injury of an employee at his place of business, where he is a manager. The lawsuit is related to what is described as inadequate safety equipment, and he explains that he is part of the group of people who are responsible for implementing safety at his workplace. The patient says the employee’s injury and disability have been upsetting for him. He also says the lawsuit has been stressful. He was disturbed when he heard about the injury, but he was able to manage the stress because he thought the employee would have a quick recovery and the legal proceedings would be resolved within a month or so.

As he began to realize the issue would not be resolved quickly, he became more and more anxious about it. He explains the work environment is anxiety-provoking because there are meetings about the lawsuit approximately once per month, often with just a few hours’ notice. It should be noted that the business and his own salary have not been impacted and he says he is not stressed about the financial implications of the situation.

He lives with his wife and he says he has maintained a calm demeanor at home. He has 2 sons in their late 20s who live on their own and he says there is no strain in his relationships with his family. Over the past years, he has been going to fewer social outings and often leaves gatherings early because he feels bored. He explains his loss of interest in social gatherings began around the same time as the lawsuit.

He reports he has felt anxious and worried for as long as he can remember, but he doesn’t remember ever complaining of insomnia, and he has never felt the need to talk to a doctor about it. The patient mentions he experienced anxiety for a year after his father died because he had to manage his mother’s home and finances when she didn’t know what to do.

Past medical history consists of allergic asthma diagnosed in his 30s for which he takes nasal steroids as needed. He also is sensitive to many foods, which give him a stomach upset and heartburn.

Stress and anxiety are linked with each other. Stress is typically a response to a situation, while anxiety is a lingering feeling of disturbance or unease. Stress can cause anxiety, which is the case in this patient’s situation. The patient’s history strongly suggests a correlation between his difficult experience at work, his anxiety, and his insomnia.

During a clinical workup, it is important to keep in mind that underlying medical issues can contribute to insomnia and anxiety. Thyroid disease and heart disease, in particular, can exacerbate patients’ symptoms. When other causes are not found, it is helpful for patients to understand symptoms such as weight fluctuation, indigestion, stomach upset, sweating, appetite changes, and sexual dysfunction can all be symptoms of anxiety.1 This patient has noted some of these effects.

, especially without a precipitating factor that is out of the ordinary, it is often described as generalized anxiety disorder (GAD).

 The patient suggests he might have GAD, but based on his detailed history, it appear he is not excessively prone to anxiety out of proportion to the circumstances of his life.

The patient described in the vignette also has signs of depression. He has lost interest in socializing and exercise, which he used to enjoy. A depression screening would be beneficial as well. Major depression occurs in almost two thirds of patients with anxiety.

Treatment of comorbid anxiety, depression, and insomnia requires a treatment strategy that is designed to avoid exacerbating any of the 3 issues. Serotonin reuptake inhibitors (SSRIs) are among the 

 Additionally, SSRIs can help reduce symptoms of insomnia for some patients.

Treatment of comorbid anxiety, depression, and insomnia requires a treatment strategy that is designed to avoid exacerbating any of the 3 issues. Serotonin reuptake inhibitors are among the first-line treatments for depression with comorbid anxiety. Additionally, SSRIs can help reduce symptoms of insomnia for some patients.

This patient started taking paroxetine (Paxil) but became very tired. He was unable to tolerate the fatigue, so the medication was discontinued. He wanted to try another medical treatment, however. He was prescribed amitriptyline (Elavil), a tricyclic antidepressant. He was more satisfied with the treatment and wanted to continue to take it. He also agreed he might benefit from counseling, as he did not see a clear light at the end of the tunnel regarding his situation at work, and he didn’t anticipate an improvement of his symptoms until the issue resolved.

• Anxiety and GAD are not the same conditions, even though people with anxiety may be prone to recurrent episodes.

• Insomnia is caused by and can cause anxiety and depression.

• Treatment of insomnia with anxiety and depression entails a strategy that is mindful of all 3 conditions.

The above case is for illustrative purposes only. Identifying factors have been changed. -Ed

1. Pharmacological Treatment of Mental Disorders in Primary Health Care. In: World Health Organization. 

Pharmacological Treatment of Mental Disorders in Primary Health Care.

https://www.ncbi.nlm.nih.gov/books/NBK143206/

2. Höglund P, Hakelind C, Nordin S. Severity and prevalence of various types of mental ill-health in a general adult population: age and sex differences. 

. 2020;20:209. doi: 10.1186/s12888-020-02557-5 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7212684/

3. Kalmbach DA, Anderson JR, Drake CL. The impact of stress on sleep: Pathogenic sleep reactivity as a vulnerability to insomnia and circadian disorders. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7045300/

4. Munir S, Takov V. Generalized Anxiety Disorder (GAD). 

Treasure Island (FL): StatPearls Publishing; 2020 Jan-. 

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5. Coplan JD, AaronsonCJ, Panthangi V, Kim Y. Treating Comorbid Anxiety and Depression: Psychosocial and Pharmacological Approaches. 

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Anxiety and stress are closely linked, and they are among the chief causes of insomnia. Watch for a variety of emotional and physical factors that may play a role in worsening depression. More in this case report.

Anxiety-Associated Insomnia With a Twist of Depression

During these uncertain times, it is easy to fall into a hole of negativity. There are so many unknowns, restrictions have been imposed on normal daily rituals, and the fear of the COVID-19 virus and potential death loom.

Yet, for years we have heard about the power of positive thinking and using laughter and happiness as a coping mechanism. Norman Cousins popularized the idea that 

. Since then, research continues to explore the role of positive and negative thinking. In fact, 

Heidi Moawad, MD, discusses the pitfalls of negative thinking and shares specific tips for heatlh professionals and the public to avoid it.

Heidi Moawad, MD

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