Medically reviewed by
Dacelin St Martin, MD
Triple board-certified in Sleep Medicine,
Internal Medicine, and Pediatrics.
Psychiatric Disorders & Sleep | Epidemiology | Risk Factors | Sleep Disorder Diagnosis | Sleep & Treatment
Overview
Sleep and psychiatric disorders often coexist with sleeplessness exacerbating the symptoms of certain psychiatric disorders, like depression, schizophrenia, generalized anxiety disorder, and bipolar disorder.
Please keep reading to find out more about these disorders, their high rate of comorbidity, risk factors, and treatment options.
Psychiatric Disorders & Sleep
Depression
There’s a high risk of comorbidity between depression, characterized by chronic and persistent feelings of sadness or hopelessness, and insomnia. If you have depression, you may have difficulty falling asleep, staying asleep, or waking up too early.
Serotonin, a neurotransmitter (also known as a chemical messenger) in the brain, contributes to sleep disruptions in people with depression. Sleep issues can affect how your body reacts to stress, increasing the risk for depression in the process.[1]
Depression and sleep problems, including insomnia and sleep disorders, like sleep apnea, are thought to have what is known as a bidirectional relationship. This term means that chronic insomnia can increase your chances of developing depression, and if you have depression, there’s a greater chance you’ll have insomnia.
Additionally, disrupted sleep may exacerbate depressive symptoms. The two conditions are so closely linked that some doctors may hesitate to diagnose depression if you’re sleeping well.
Schizophrenia
Approximately 1 percent of the population has schizophrenia, a mental disorder associated with losing touch with reality. If you have this disorder, you can experience hallucinations and exhibit delusional behavior. You may have a hard time putting together rational thoughts and be unable to properly express yourself.
Research suggests that overactive dopamine receptors in the brain can result in symptoms of schizophrenia. This physiological response leads to increased wakefulness, which is a contributing factor to insomnia.[2]
Dopamine is also a neurotransmitter, one the nervous system uses to communicate between your nerve cells. If your body produces too much dopamine, you’ll find it hard to sleep. Conversely, you’ll feel drowsy if your body doesn’t produce enough.
Schizophrenia can cause irregular sleep patterns. Most people with a healthy sleep pattern typically get seven or eight hours of sleep, while people with schizophrenia can sleep at any time of the day or night. They may sleep too long, or they may not sleep long enough. Fear and anxiety may make it hard to sleep at all.
If you have schizophrenia, you may be at a higher risk of developing obstructive sleep apnea (OSA). Researchers conducting a study of patients with severe mental illnesses undergoing treatment at a primary care clinic found that 62 percent of the patients with schizophrenia also had OSA.[3]
Generalized Anxiety Disorder (GAD)
Generalized anxiety disorder (GAD) is a common mental health disorder that is characterized by 6 or more months of consistent and persistent worrying that interferes with day-to-day life. Symptoms are often physiological responses to hyperarousal and muscle tension, which can lead to sleep disturbance and excessive daytime arousal.
Anxiety is an evolutionary mechanism designed to keep you safe; however, those with GAD are alerted to the perceived danger to an excessive degree that is not in line with the actual situation. This hyperarousal can lead to sleep-wake disturbances that can worsen over time.
GAD has been linked to the dysfunction of the neurotransmitter system, making sleeplessness one of the key symptoms of the disorder.[4] Hormonal imbalances involving CRH, adrenocorticotropic hormone (ACTH), or Cortisol can lead to delayed sleep onset, reduced short-wave sleep, and increased sleep fragmentation.[5]
Bipolar Disorder
This condition is characterized by periods of extreme moods. You may alternate between feelings of euphoria and boundless energy and bouts of severe depression. If you’ve been diagnosed with bipolar disorder, you may be predisposed to develop a sleep disorder, like:
- Insomnia: The fear and anxiety associated with depression can make it hard for you to sleep during your “low” periods with bipolar disorder. Conversely, when you’re “up,” you have so much energy you might find it impossible to sleep.
- Irregular sleep-wake schedule: If you have bipolar disorder, you may have difficulty establishing a sleep routine.
- Nightmares: Bipolar disorder can often result in extremely vivid dreams, as well as nightmares.
- Parasomnias: These disorders can include sleepwalking and sleep talking.
Sleeplessness can often lead to anxiety, increasing the possibility of a manic episode, which turns into a vicious cycle. If you can’t get to sleep and go into a manic state, it makes it even harder to sleep, making it likely that you’ll experience even more manic episodes.
Scientists believe that artificial light may be one reason you have problems with sleep if you have bipolar disorder. It’s likely that if you are already genetically predisposed to bipolar disorder, artificial light may increase the risk of the condition.[6]
Epidemiology: Sleep & Psychiatric Disorders
Depression
Researchers in one study, involving subjects between the ages of 21 and 30 who suffer from depression, found that 50 to 60 percent of these subjects also experience insomnia.
A more comprehensive study, involving more than 8,500 subjects, found that 83 percent of people with depression had insomnia, compared with 36 percent of study subjects who didn’t have insomnia.[7]
Schizophrenia
There’s a strong likelihood of comorbidity between schizophrenia and restless legs syndrome (RLS). With RLS, you feel compelled to move your legs during sleep or moments of rest, to alleviate unpleasant sensations.
According to one study, between 21 and 47 percent of subjects with schizophrenia exhibited RLS, compared to 9 and 19 percent of subjects in a control group.[8]
Bipolar Disorder
Researchers have found that between 25-65 percent of those with bipolar disorder who suffered a manic episode had a sleep-wake disruption beforehand.[9]
Anxiety Disorders
Anxiety disorders are one of the most commonly occurring categories of mental illness, with an estimated 10% to 25% of the generalized population having one of the disorders.[10]
Risk Factors
In certain instances, sleep problems can be predictors for the development of mental disorders.
Depression
Insomnia for two or more weeks, virtually every night, can be a significant predictor of a major bout of depression.[11]
Schizophrenia
Researchers found that young people at ultra-high risk for psychosis who experience issues with sleeplessness or increased bodily movements during sleep were more likely to develop psychotic symptoms.[12]
Bipolar disorder
If you have bipolar disorder and have a sleepless night, it’s a good predictor of a mood swing. A consistent sleep-wake schedule is imperative in the management of this disorder.[13]
Anxiety Disorder
With anxiety disorders, insomnia appeared mostly at the same time (>38%) or after (> 34%) the anxiety disorder. In addition, it was concluded that an anxiety disorder is linked to the severity and chronicity of insomnia.[14]
Sleep Disorder Diagnosis
Regardless of the psychiatric disorder, doctors have many tools at their disposal to diagnose sleep disorders, such as:
1) Questionnaires
The diagnosis of sleep disorder can be made based on typical symptoms and an assessment of lifestyle habits. The doctor may administer a sleep questionnaire, like the Sleep Timing Questionnaire (STQ), that collects information regarding 2 weeks’ worth of sleep data, similar to the information collected in a sleep diary.
Your doctor may also try to gauge your anxiety levels by asking additional questions, like:
- Are you experiencing any sort of anxiety regarding your inability to sleep? In other words, do you worry about not being able to sleep before or once you get into bed?
- Do you tend to watch the clock while you’re in bed?
- Do you deal with disturbances during the night, such as a snoring partner, a barking pet, or a crying child?
2) Sleep Diary
Your doctor may also request that sleep be documented in a diary, which records the total time spent sleeping, wake times, the occurrence of daytime sleepiness, and the frequency of naps.
3) Polysomnography
Polysomnography is a diagnostic test and is performed in a laboratory while you are asleep. You’re connected to a device that measures your heart rate, respiratory rate, and oxygen saturation.
It’s typically used for sleep-related breathing disorders, like obstructive sleep apnea. Still, it can be used in conjunction with other tests to diagnose restless legs syndrome, narcolepsy, and certain parasomnias.
4) Actigraphy
An actigraphy uses a non-invasive portable device called an accelerometer that monitors activity and rest cycles during the day.
This device is worn on the wrist or ankle. This test helps determine different sleep parameters, such as total sleep duration and the periods of wakefulness.
This test usually lasts for one week and provides information about sleep patterns.
Sleep & Treatment
The treatment of particular psychiatric conditions can improve sleep, while empirical evidence shows that addressing sleep disorders can have a significant effect on the treatment of psychiatric disorders, like bipolar disorder.[15]
If you have depression, prescribed antidepressants, like eszopiclone, mirtazapine, and trazodone, can help improve your sleep; however, you may be at risk for relapse at a later time.
As for schizophrenia, poor sleep can exasperate symptoms, and compromise the effectiveness of medications. Schizophrenics can experience fluctuations in sleep, so it’s important to identify potential triggers, like medications, medical issues, or changes in routine.[16]
Don’t Give Up Hope
If you have a psychiatric disorder and suffering from sleeplessness, your best course of action is to speak to your doctor.
References:
- Meerlo Peter, Sgoifo Andrea, Suchecki Deborah. Restricted and disrupted sleep: effects on autonomic function, neuroendocrine stress systems and stress responsivity. Sleep Med Rev. 2008 Jun;12(3):197-210. doi: 10.1016/j. PMID: 18222099. Retrieved from <https://pubmed.ncbi.nlm.nih.gov/18222099/>
- Kaskie Rachel E, Graziano Bianca, Ferrarelli Fabio. Schizophrenia and sleep disorders: links, risks, and management challenges. Nat Sci Sleep. 2017; 9: 227–239. 2017 Sep 21. doi: 10.2147/NSS.S121076. PMID: 29033618. Retrieved from <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5614792/>
- Abdulkader Alam, Chengappa K N Roy, Frank Ghinassi. Screening for obstructive sleep apnea among individuals with severe mental illness at a primary care clinic. Gen Hosp Psychiatry. Nov-Dec 2012;34(6):660-4. doi: 10.1016/j.genhosppsych.2012.06.015. PMID: 22832135. Retrieved from <https://pubmed.ncbi.nlm.nih.gov/22832135/>
- Kent, J. M., Mathew, S. J., & Gorman, J. M. (2002). Molecular targets in the treatment of anxiety. Biological psychiatry, 52(10), 1008–1030. https://doi.org/10.1016/s0006-3223(02)01672-4
- Van Reeth, O., Weibel, L., Spiegel, K., Leproult, R., Dugovic, C., & Maccari, S. (2000). Interactions between stress and sleep: from basic research to clinical situations. Sleep medicine reviews, 4(2), 201-220.
- Harvey Allison G, Kaplan Katherine A, Soehner Adriane M. Interventions for Sleep Disturbance in Bipolar Disorder. Sleep Med Clin. 2015 Mar;10(1):101-5. doi: 10.1016/j.jsmc.2014.11.005. PMID: 25750600. Retrieved from <https://pubmed.ncbi.nlm.nih.gov/25750600/>
- Nutt David, Wilson Sue, Paterson Louise. Sleep disorders as core symptoms of depression.Dialogues Clin Neurosci. 2008 Sep; 10(3): 329–336. doi: 10.31887/DCNS.2008.10.3.PMID: 18979946. Retrieved from <https://pubmed.ncbi.nlm.nih.gov/18979946/>
- Kaskie Rachel E, Graziano Bianca, Ferrarelli Fabio. Schizophrenia and sleep disorders: links, risks, and management challenges. Nat Sci Sleep. 2017; 9: 227–239. 2017 Sep 21. doi: 10.2147/NSS.S121076. PMID: 29033618. Retrieved from <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5614792/>
- Frank Ellen, Swartz Holly, Boland Elaine. Interpersonal and social rhythm therapy: an intervention addressing rhythm dysregulation in bipolar disorder. Dialogues Clin Neurosci. 2007 Sep; 9(3): 325–332. doi: 10.31887/DCNS.2007.9.3. PMID: 17969869. Retrieved from <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202498/>
- Wittchen, H. U., Essau, C. A., & Michels, R. (1993). Epidemiology of anxiety disorders. https://books.google.com/books?id=WSFnDAAAQBAJ&lpg=PA19&ots=c084cRyIgf&lr&pg=PA19#v=onepage&q&f=false
- Breslau N, Roth T, Rosenthal L, et al. Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Biol Psychiatry. 1996 Mar 15;39(6):411-8. doi: 10.1016/0006-3223(95)00188-3. PMID: 8679786. Retrieved from <https://pubmed.ncbi.nlm.nih.gov/8679786/>
- Lunsford-Avery Jessica , Monique K , Gupta Tina, et al. Actigraphic-measured sleep disturbance predicts increased positive symptoms in adolescents at ultra high-risk for psychosis: A longitudinal study. Schizophr Res. 2015 May; 164(1-3):15-20. doi: 10.1016/j.schres.2015.03.013. PMID: 25818627. Retrieved from <https://pubmed.ncbi.nlm.nih.gov/25818627/>
- Steardo Luca, de Filippis Renato, Carbone Elvira, et al. Sleep Disturbance in Bipolar Disorder: Neuroglia and Circadian Rhythms. Front Psychiatry. 2019 Jul 18. doi: 10.3389/fpsyt.2019.00501. PMID: 31379620. Retrieved from <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6656854/
- Ohayon, M. M., & Roth, T. (2003). Place of chronic insomnia in the course of depressive and anxiety disorders. Journal of psychiatric research, 37(1), 9–15. https://doi.org/10.1016/s0022-3956(02)00052-3
- Krystal A. D. (2012). Psychiatric disorders and sleep. Neurologic clinics, 30(4), 1389–1413. https://doi.org/10.1016/j.ncl.2012.08.018
- Lampner, C (March 1, 2019) Expert Perspective: Treating Insomnia in Patients With Schizophrenia. Psychiatry Advisor. https://www.psychiatryadvisor.com/home/schizophrenia-advisor/expert-perspective-treating-insomnia-in-patients-with-schizophrenia/
