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  • Erin Tahvonen, LMHC

When counting sheep fails: Understanding sleep patterns in mental health


Sleep is a primary complaint of people struggling with mood dysregulation and central diagnostic criteria in several psychiatric disorders. Frequently, individuals experience insomnia which involves difficulty falling asleep or staying asleep, but can also present as hypersomnia, resulting in excessive sleepiness despite prolonged periods of sleep. It is helpful to understand patterns of sleep disturbance in order to obtain or provide an accurate diagnosis:


Generalized Anxiety Disorder


More than 50% of individuals diagnosed with GAD experience insomnia. People who suffer from GAD report increased number of arousals per night, greater time spent awake during the night, and a higher percentage of sleep time in Stage 1 Sleep (Krystal, 2012), a light phase of sleep primarily involving beta waves that represent a state between wakefulness and early sleep.


How GAD might be affecting your sleep:

  • You struggle to fall asleep or wake in the night and find it difficult to shut your mind down enough to rest.

  • You worry about whether you'll be able to sleep

  • When you wake, you feel as though you're not well rested due to the excessive time spent in light sleep phases, and the lack of time spent in deep sleep.


Major Depressive Disorder


For those suffering from depression, both insomnia and hypersomnia are frequently noted. Findings suggest in both cases depression is correlated with a shorter time from onset of sleep to the REM Phase, increased REM density (more eye movement), higher percentage of the night spent in the REM Phase, and a decrease in slow-wave (deep) sleep (Luik, Zuurbier, Whitmore, Hofman, Teimeier, 2015).


How MDD might be affecting your sleep:

  • You may experience difficulty falling asleep and staying asleep, or you might feel like you could sleep for ages

  • In either case, you wake up without experiencing the restorative effects of sleep and may feel like you wake exhausted

  • You may experience more vivid dreams and begin dreaming earlier in the night than non-depressed individuals.


Bipolar Disorder


One symptom of mania and hypomania is “decreased need for sleep, for example feeling rested after only 3 hours of sleep (DSM-5).” This lower need for sleep should not be confused with insomnia, as mania-related sleep disruption does not present with the same impairment in functioning associated with insomnia. Hypersomnia is more common in the depressive phase of bipolar depression compared to unipolar depression (Krystal, 2012).


How Bipolar Disorder might be affecting your sleep:

  • You have experienced at least one episode of mania or hypomania in your lifetime, which involved sleeping very little without growing tired or feeling daytime exhaustion in response to this sleep deprivation.

  • You've experienced at least one depressive phase and during this time it is likely you sleep excessively but do not feel restored, instead continue to feel exhaustion despite sleep.

  • You may struggle in a more general way with regulating your sleep-wake cycles.

  • Changes in your sleep may precipitate changes in your mood.


PTSD

“Recurrent, distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s)” is a symptom of Post-Traumatic Stress Disorder (DSM-5). Individuals have similar dysregulation of REM Phase similar to MDD and increase number of nighttime arousals similar to GAD (Krystal, 2012).


How PTSD might be affecting your sleep:

  • You may experience vivid, disturbing dreams about the source of your traumatic experience, in an aroused physical state as if you're reliving the experience, or the dreams may be about other distressing events.

  • You may have difficulty falling asleep or wake very early.

  • Sleep can feel intimidating for several reasons such as wanting to avoid nightmares, experiencing hyperarousal so it is difficult to relax enough to sleep well, waking to small sounds in your environment, and generally feeling a lack of control when you are asleep.

  • Due to the light sleep patterns, it is likely you do not feel well-rested after sleep.


Treating Sleep-Related Symptoms


Insomnia triggers Sympathetic Nervous System arousal, including elevated cortisol and body temperature, increased brain activity prior to sleep, and negative cognitions related to sleep (Ong & Smith, 2017). Several treatment avenues are available to help address this dysregulation:


Exercise.

A study investigating sleep as an adjunct to therapy for women with GAD showed engaging in aerobic or resistance training twice per week decreased time to sleep onset and improved sleep continuity (Herring, Kline, O’Connor, 2015).


Cognitive Behavioral Therapy.

CBT has long been a primary treatment modality for sleep impairment, which is addresses the negative cycle that emerges from negative thoughts about sleep and bi-directional effects of psychiatric disorders and insomnia. Challenging the beliefs and cognitions, as well as incorporating behavioral skills such as deep breathing, guided imagery, and progressive muscle relaxation can have a significant impact (Ong & Smith, 2017). However, more recent studies show the efficacy increases by including a focus on:


Mindfulness.

Mindfulness involves a “non-judgmental awareness of mental and physical states (Ong & Smith, 2017),” a skill that can be learned through the therapeutic process. Ong & Smith (2017) found mindfulness had an impact on insomnia through three primary mechanisms: 1.) Increasing mindful awareness (acknowledging sensations related to sleep and wakefulness, including thoughts and behaviors that arise due to insomnia). 2.) “Metacognitive shifting” by which you learn to observe without judgement thoughts related to sleep rather than problem-solving the sleep concerns. 3.) Developing a “mindful stance” merges the awareness and metacognition to decrease arousal and shift focus away from sleep to other important life goals.


Medical Screening.

If you're struggling with sleep issues, it is important to talk to your primary care physician to rule out health conditions or the need for a sleep study. Sleep Apnea is one potentially dangerous sleep disorder that should be excluded that can be highly correlated with mental health disorders.



If you are suffering from disrupted sleep patterns, your symptoms can quickly have an impact on your mood and ability to regulate your emotions. Reach out or contact your provider to get help managing these symptoms today.



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