HELP! Chicken and Egg Question: Insomnia and Anxiety

[cynic]

Hi,

I have a chicken-and-egg question: Does anxiety/depression cause insomnia or does insomnia trigger anxiety attacks or depressed mood?

I've had days when I couldn't sleep for no known reason. Then as the night progresses and I'm still wide awake, my anxiety heightens and this would continue on the next day, which eventually leads to fear of not being able to sleep again at night.

And of course, my anxiety is always accompanied by depression, which I think exacerbates my sleeplessness.

What should I do? Really need your advice.

[Robbed]

My anxiety problem also started with sleeplessness. Here's how I see things. Anxiety is caused by stress. This causes symptoms of stress to appear. Many of these symptoms are rather subtle, and/or are written off as the result of something else. Then, a particularly troubling symptom kicks in, which causes GREAT fear. And, all too often, this symptom is insomnia. After all, we can live with ALOT of unpleasant symptoms. But if you can't sleep, you can't function. And because we just can't see a solution to insomnia, it is VERY scary. Indeed, Claire Weekes defines the beginning of an anxiety disorder as that point where you develop a fear of your symptoms.

As for depression, this can have numerous causes. In fact, depression (much like a headache) is better looked at as a symptom than a disease. Much depression is cognitively based. But from what I have experienced with my own experience with anxiety, the depression that accompanies anxiety seems to be more chemical than cognitive - a result of the havoc anxiety wreaks on the brain. The good news, though, is that the depression improves as the anxiety improves.

But back to your sleep. This can be a VERY troubling thing to deal with. There are numerous CBT techniques that are often employed to deal with this, such as trying not to fear sleeplessness, getting up if you have been awake in bed for over 20 minutes, using your bed for sleep only, etc. However, these things can sometimes make matters worse (it can bar you from doing things you actually find relaxing, like maybe going online with your laptop in bed). And it is hard NOT to fear sleeplessness if you have sleepless night after sleepless night. If this is the case, then sleeping pills are your best bet. Although most of us don't like medication, keep in mind that sleeping pills are a far cry from SSRIs. They are used only when needed. And side effects are generally minimal (especially compared with SSRIs).

[cynic]

Hey Robbed, thanks for your reply. I really appreciate it a lot. It was very enlightening.

Yes, sleeplessness causes me great fear. And you are right. Some of the symptoms of anxiety, I can live with, but insomnia--oh no. I'm telling you, it was such a horrible experience for me. Last year, when I first experienced this disorder, the first week, there were two days (but not continuous that I didn't get any sleep at all) to the point that I almost wanted to tell my friend, "please get me to the hospital and tell them to sedate me." So, I thought, I just needed to get some sleep and I'll be okay. The second week as my body clock was being reset, the amount and quality of sleep I had was improving. I was actually getting 8 hours already. But there was still that fear and then during the day, I couldn't think of anything but my condition. I couldn't concentrate which was really bad because I work in the academe as a full-time researcher. Sometimes I would take naps at the office, but it was like a passing-out feeling. And when I wake up, there is still that fear looming. It went to a point where I thought I was going crazy, which of course scared me again.

When it was already unbearable, I finally sought the help of a psychiatrist. She put me on Lexapro (10 mg) because she noticed I was already showing signs of depression (crying spells, etc.) and gave me Stilnox (or Ambien in the US right? It's Zolpidem). I took Lexapro but not Zolpidem coz I was thinking, "no way am I going to take sleeping pills." I was actually already sleeping fine but when I wake up in the morning, there is that fear and being on the edge and thinking I was going crazy. Then the day after I took my first Lexapro, I think I had an anxiety attack after waking up from a 1-hour "nap" (more like passing out again). I was nauseated and couldn't breathe. She put me on Clonezapam for a week and asked me to take a 3-week leave. I was actually fine after. I never exhibited the side effects of both Lexapro and Clonezapam. I went through 3 months of psychotherapy. I am still on Lexapro (5 mg). She said more of prophylactic. I never took Zolpidem for fear I might develop dependence.

I fear that going through a big event in my life--moving to the US--this coming fall, I might exhibit symptoms of anxiety again. And yes, as you said, I haven't overcome my fear of sleeplessness.

How have you dealt with this? I would really love to hear how have you overcome this scary symptom of anxiety.

[Lulu]

Hi Cynic

My god, I didn't know whether to laugh or cry when I read your post because it's so true to my own life.

I've had anxiety symptoms since I was 18 but off and on, maybe a year of these symptoms and then 7 without. Last May however i was going through a difficult phase at work, and although i didn't feel myself stressing over it too much I was experiencing evening headaches etc. Then I began to have trouble sleeping and like you literally no sleep at all. Im sure some evenings I managed to get a couple of hours but it didn't feel like it. One day at work I had a huge panic attack, and even though I'm used to them this one took over. I ended up being admitted to hospital that day just overnight so they could keep an eye on me. My GP prescribed me propanolol, which are beta blockers. These are ok but unless you take them regular not really any good. After a week or so and still suffering from constant insomnia and anxiety I thought I was goign to go mad so she put me on Seroxat. After a few weeks these symtoms abated and I went back to work and sleep returned.

However, over the last year that feeling of anxiety has never gone. About a month ago my husband was laid off from work, again I didn't feel like I was worried about it but the insomnia returned. As did the anxiety symptoms. Believe me, I know how awful these are. I feel sometimes I'm living in a box, I watch other people and I ask myself, Why aren't I liek that? Why are they walking around and happy and relaxed? I have genuinly forgotten what that feels like. I know I'm depressed, and for the life in me I dont' know which came first, depression or anxiety. I know I'm depressed because of these feelings, because I'm angry with myself for getting this way, because I'm scared of never getting better. I have cried and cried over this the last few weeks. I can wake up in the morning feeling good and go to bed feeling like crap.

There are no easy ways of managing these feelings. For me I escape, i go for a long walk on my own. Or finding someone who you can talk to about it, someone who knows you, and you don't feel silly also helps. The problem being is that people will listen but unless they experience it they don't really understand what you're feeling.

I know for me the best thing I could do for myself is to accept this is me instead of being so bloody angry and depressed about it. It has robbed me of a certain amount of confidence it has to be said, but I try to push myself to do things that scare me in case I panic. Then I can be proud of myself for doing it.

Anyway, just another point of view :-)

[cynic]

my god, lulu, are you my soulmate or something? :D

you're the one who's moving to NYC right? and i'm going to OC and anxious about it!

you know, i feel like i'm not myself anymore. the old me would be all excited about traveling--new adventures, new people. i am the girl who lives to explore the world, who plans to go to new places every year. and i did--i was able to do it. i'v been looking at my old pictures and i feel like crying sometimes. damn, i was so happy then!

it is true what you said. anxiety shouldn't take over your life. but it's hard.

well for a year now, i feel fine. still on meds though, but i could go for a week without taking them and still feel fine. (my psychiatrist though told me not to do it again without consulting her) and i did travel (i keep stressing this because i have always been an overworked academic and traveling has always been some kind of therapy for me). but now, the anxiety is back--maybe because i'll be gone for more than a month or maybe because it's not vacation anymore. *sigh*

sometimes, i think: should i even go? what if i'm all messed up when i come back home? i'll be on a scholarship to do graduate studies and i keep thinking, what if i'll be too anxious and depressed to perform well in school?

it sucks. i still haven't accepted the fact that i have this disorder.

what you said made me think though. it really helps. do you mind if i PM you once in a while?

[Lulu]

Hey PM away!

I'm going to new york for a month not moving there permanent. Hey I know exactly what you mean about getting excited about travelling. I can't get excited about much these days before stressing about it first. Everyone has different types of anxiety, i haven't realy figured mine out as yet. When I'm actually on holiday i'm at my best, I'm so relaxed and carefree I hate coming back.

It seems to be the day to day things that start me off, and the ridiculous thing is I don't even have really that stressful a life!! I work as a Medical Secretary part time, and I'm a Bereaement officer at the weekends.

I'll tell you a story. Today I had to work in the mortuary. I go in if I get called out to get the deceased ready and sit with the family whilst they say goodbye. Well today I had a 13 year old boy who'd passed this week. After his parents had gone, and I was putting this kid back in "bed" i was thinking to myself, how selfish am I? Surely what these parents are going through is much much worse than how I feel. And shouldn't that thought alone be enough to pull me out of this? Apparantely not, I came home and I was on my own in the house and I felt the anxiety creep back.

I will forever spend my life searching for answers to this, and fighting it. I'm thankful I'm not teh kind of person who lies down and takes it all. And you sound the same way. So keep moving forward in yoru life, and whenever you're scared of something NEVER give in, make yourself do it. Do it in your own way though. And tell yourself, you know what, ok I was scared or this is scaring me, but I did it, and I'm proud I didn't give in to it. Because once you start giving in you've had it.

Hope my rambling helps 8)

[abcdefghix]

I have had difficult struggles with sleep in the past, so I know exactly what you are going through. When I was in the military, my fears of not getting a good night's sleep became so severe that I routinely suffered from full-night insomnia. At one point, the insomnia lasted for four straight days. But, since I started with Acceptance and Commitment Therapy (ACT), I rarely get less than eight hours. In fact, I have the opposite problem: I have a hard time not falling asleep when I need to be awake.

In my struggles, I tried everything: breathing exercises, positive imagery, guided meditation, and so on. None of it worked. In fact, the efforts made it more difficult for me to get to sleep.

The only sleep hygiene that worked for me was to keep the room cold, dark, and quiet. Maybe a hot bat and a glass of milk or a bowl of cereal before bed (get some carbs in you). Everything else was useless.

The problem with sleep is that it works differently from what we are used to. Normally, when we encounter a problem, we try to solve it with overt effort. When we experience insomnia, we think,

"OK, I'm going to get a plan together to stop this from happening. I'm going to go to bed every night at 10PM on the dot. I'm going to do some deep breathing exercises. I'm going to set the bed up perfectly, and lie down and just sleep. I'm not going to let myself get caught up in fear, nervousness, or negative thinking. I'm just going to sleep like everyone else does."

Unfortunately, when we take this approach, the mind becomes hypervigilant. It starts to think more about sleep, and to routinely check to see if the efforts to get to sleep are working.

So you're lying in bed and the thoughts will come up "Is this working?" "Am I sleeping yet?" "Stop thinking, go to sleep..." "I wonder if this is going to work?" "Nothing works..." "F-ck! Go to sleep!!!" 1AM.. 2AM.. 6AM.. alarm rings, time to go to work. You know the rest.

Here is the lesson I learned from ACT. You cannot control sleep. Only your body can control sleep. You have to see it this way and let it be this way--because that is how it really is. Sleep is not a conscious process, it is entirely unconscious. So you have to take your hands off of it and let your body determine the outcome. And when your body only decides to get 3 hours of sleep, you need to let that happen--even though it pisses you off. Let your body make the decision as to when and whether it will fall asleep, even though the decision might rough up up your day. Your body will not let you die of insomnia, trust me. It will get the sleep that it needs.

If you try to make sleep happen, if you try to take control of sleep away from your body, if you try to enact a routine for minimizing the effects of negative thoughts about sleep, sleep definitely will not happen. Nothing overt will work, because the mind will get overvigilant about it. The entire process will become a huge, counterproductive struggle.

When you lie in bed, thoughts are going to come up. That's normal. You are not causing that, your mind is, so you don't need to get mad at yourself or blame yourself. When it happens, just let it happen. And when you get pissed off, let yourself get pissed off. Just sit back and let the feelings happen. If you can, it helps to let go of your attachment to sleep. You might just say "whatever" and stay awake. Treat it as if it isn't your problem to worry about. So if you find yourself wide awake at 3AM, maybe part of you will be able to say "f-ck it" and just get up and grab some food and surf the net for awhile. Enjoy the extra free time.

The idea is to flow with whatever comes up in a light, unattached manner. If we don't sleep, then we don't sleep. OK, what next? Sure, the day will suck, but it's not like we've never had any of those kinds of days before. We get through them.

Harvard psychologist Daniel Wegner has a theory about sleep which is highly accurate. He has shown that when an individual tries really hard to do something in a deeply attached and invested manner, the mind habitually checks to see if the efforts are working. Wegner has shown in studies how this very process leads to most stress-related insomnia. So ou are not a special snowflake.

See these two articles:

http://www.wjh.harvard.edu/%7Ewegner/seed.htm

http://www.wjh.harvard.edu/~wegner/pdfs ... 201996.pdf (http://www.wjh.harvard.edu/~wegner/pdfs/Ansfield,%20Wegner,%20&%20Bowser%201996.pdf)

Best wishes,
--abcdefghix

--------------------------------------------------------------------------------------

I would urge anyone who struggles with anxiety to buy the following workbook,

Get Out of Your Mind and Into Your Life

by Dr. Steven Hayes.

http://www.amazon.com/Get-Your-Mind-Int ... 843&sr=8-1 (http://www.amazon.com/Get-Your-Mind-Into-Life/dp/1572244259/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1216669843&sr=8-1)

The author is a world reknowned psychologist who himself has suffered from panic disorder. Unlike many psychologists, he understands what we go through, because he has gone through it himself. He knows what actually works and what doesn't, and has developed a new evidence-based psychotherapy that has shown tremendous results in multiple clinical trials (for GAD, SAD, OCD, Panic, and Depression).

Just the workbook alone was enough to completely change my life.

You can read more about Dr. Hayes and his amazing journey from house-bound anxiety patient to president of the APA (American Psychological Association) in the following Time Magazine article:

http://www.time.com/time/magazine/artic ... 13,00.html (http://www.time.com/time/magazine/article/0,9171,1156613,00.html)

[Robbed]

In my struggles, I tried everything: breathing exercises, positive imagery, guided meditation, and so on. None of it worked. In fact, the efforts made it more difficult for me to get to sleep.

The only sleep hygiene that worked for me was to keep the room cold, dark, and quiet. Maybe a hot bat and a glass of milk or a bowl of cereal before bed (get some carbs in you). Everything else was useless.

The problem with sleep is that it works differently from what we are used to. Normally, when we encounter a problem, we try to solve it with overt effort. When we experience insomnia, we think,

"OK, I'm going to get a plan together to stop this from happening. I'm going to go to bed every night at 10PM on the dot. I'm going to do some deep breathing exercises. I'm going to set the bed up perfectly, and lie down and just sleep. I'm not going to let myself get caught up in fear, nervousness, or negative thinking. I'm just going to sleep like everyone else does."

Unfortunately, when we take this approach, the mind becomes hypervigilant. It starts to think more about sleep, and to routinely check to see if the efforts to get to sleep are working.

This is all VERY true about all of the CBT methods that SO many therapists recommend when it comes to insomnia. The way I see it, there are TWO big problems here. The first one is the fact that, by deviating from your normal bedtime routines (which, by the way, were NEVER a problem before, and are certainly NOT the problem now), you are basically TELLING yourself subconsciously that sleep is a problem, and that steps need to be taken to correct it. And, as you say, this leads to hypervigilence. Also, doing many (if not MOST) of us do things that therapists say you should NOT do if you have sleep problems can cause you to be less relaxed. These things are often things we like doing. MANY of us like to read before going to sleep, go online with the laptop before going to sleep, or use our bedrooms for reasons other than sleep. With this last one, many of us may have little choice: your bedroom might be your only private place. Having to change your routine in order to practice 'better sleep hygiene' will very likely mean giving up something that you find enjoyable and relaxing, which could very well exacerbate your sleep problem. Indeed, the best thing to do is to try to accept the problem as best as you can. On the other hand, sleep medication would probably not be a bad idea if you experience sleepless night after sleepless night. After all, this can often make things MUCH worse as far as anxiety goes.

[cynic]

Dear abcdefghix and Robbed,

Thank you so much for your insights. They really help.

And you know, what you said about hypervigilance is all true!!! Case in point: I work as a researcher. I love to read academic (social science) books before bed. I've been doing it for god knows how long. But I had to give it up, because doc says I shouldn't be doing anything intellectual a few hours before going to sleep. There are so many things I shouldn't do, which I truly enjoyed before--part of my night time routine. The more things people tell me to do or not do, the more I get stressed and get frustrated when they don't work!

But the thing is, abcdefghix, I don't have your attitude. I wish I have, so I don't really feel like crap the next day. I just become too anxious to function and develop a fear of not being able to sleep again the next night. For a time, every time the sun sets, I was like, "Oh no, it's night time again."

My doc prescribed me Zolpidem, but I never took it. Robbed, have you taken them before? Are they safe?

abcdefghix, I have yet to check the links you posted. Thanks so much.

Best,
cynic