People diagnosed with mental illness frequently have related sleep problems. Most often, sleep problems related to mental illness involve one of two conditions:
- Insomnia. Condition in which a patient has trouble falling asleep or remaining asleep. Typically, patients with insomnia do not feel refreshed after a night’s sleep. Insomnia may be acute (short term) or chronic (lasting for longer than one month).
- Hypersomnia. Condition that causes people to feel extremely sleepy throughout the day. Patients with hypersomnia also often sleep for long periods at night and nap repeatedly during the day. However, sleep in hypersomnia does not leave the patient feeling refreshed or more alert.
A large number of mental illnesses may cause sleep problems such as insomnia or hypersomnia. These include adjustment disorders, bipolar disorder, generalized anxiety disorder, panic disorder, personality disorders, schizophrenia and somatoform disorders.
People with sleep disorders that are associated with mental illness are likely to display two sets of symptoms. The first set of symptoms is related to the mental disorder itself. The second set of symptoms is related to the sleep problems and includes fatigue, increased anxiety at bedtime and difficulty concentrating throughout the day.
In most cases, a patient’s sleep problem will be diagnosed and treated along with other symptoms of the associated mental illness. However, if the patient’s complaints are primarily focused on sleep problems, one of two diagnoses may be made according to specific criteria established by the American Psychiatric Association: insomnia related to another mental disorder or hypersomnia related to another mental disorder.
About sleep and mental illness
People diagnosed with mental illness often have related sleep problems. In most cases, a person’s sleep problem will progress in tandem with the underlying mental health disorder responsible for the disruption of sleep. Sleep problems often emerge early in the illness, before symptoms characteristic of the mental illness even begin to appear.
Most often, sleep problems related to mental illness involve one of two conditions:
- Insomnia. Condition in which a patient has trouble falling asleep or remaining asleep. Typically, patients with insomnia do not feel refreshed after a night’s sleep.
- Hypersomnia. Condition that causes people to feel extremely sleepy throughout the day. Patients with hypersomnia also often sleep for long periods at night and nap repeatedly during the day. However, this sleep does not leave the person feeling refreshed or more alert.
A large number of mental illnesses – ranging from the anxiety disorder post-traumatic stress disorder (PTSD) to postpartum depression – can cause sleep problems such as insomnia and hypersomnia. For example, all forms of depression are commonly associated with sleep problems. People who are depressed often experience bouts of insomnia that may cause them to have difficulty falling asleep, remaining asleep or falling back asleep after waking early in the morning. Less frequently, depressed patients may have problems with hypersomnia that cause them to sleep excessively.
Sleep consists of five stages, the first four of which are called non-rapid eye movement (REM) sleep. Stage 1 is the transition from being awake to sleeping, stage 2 is an intermediate level of sleep, and the third and fourth stages may be referred to as deep sleep or slow wave sleep. The fourth stage is also known as delta sleep, which is the deepest type of sleep. During delta sleep, growth hormone, which regulates cell division and protein synthesis necessary for growth, is produced. The fifth stage of sleep is called REM sleep. Dreaming occurs during this stage. Sleep is an active, complex process that involves the brain in multiple ways.
Mental illnesses often associated with sleep problems such as hypersomnia and insomnia include:
- Adjustment disorders. Conditions in which a person has an excessive reaction to a stressful life event, such as starting school or getting divorced. Insomnia often accompanies these conditions.
- Bipolar disorder. Condition in which periods of excitability (mania) alternate with episodes of depression. Hypersomnia is often associated with this condition.
- Generalized anxiety disorder. Condition in which a person displays frequent patterns of worrying about activities or events. Patients with this condition often report insomnia that makes it difficult to fall asleep and that may cause them to awaken with feelings of anxiety during the night.
- Panic disorder. Condition marked by recurrent episodes of intense fear and anxiety that may last for minutes to hours. Patients with this condition may experience panic attacks in the middle of the night that cause them to awaken and to then struggle to fall asleep afterward.
- Personality disorders. Conditions marked by inflexibility in perceiving, reacting to and relating to people and events. People with personality disorders often have impaired social skills. Insomnia often accompanies these conditions.
- Schizophrenia. People with this condition struggle to distinguish between real and unreal experiences. They may not think logically or have normal emotional responses to others. Insomnia often accompanies periods when symptoms related to schizophrenia intensify.
- Somatoform disorders. Condition in which patient complaints of persistent or chronic symptoms of physical illness are believed to be at least partially associated with a mental health condition. Insomnia often accompanies somatoform disorders.
- Seasonal affective disorder (SAD). People with SAD typically experience symptoms of depression in the winter months, but not in the spring or summer months. Sleep problems associated with SAD include oversleeping, difficulty staying awake during the day, disturbed sleep and, in some cases, waking exceptionally early in the morning.
The treatment for certain mental health disorders may predispose the patient to developing sleep problems. For example, prescription medications to treat anxiety disorders (e.g., benzodiazepines) interrupt the normal sleep cycle by increasing the amount of stage two sleep and decreasing the amount of sleep in stages three and four and REM sleep. The deeper sleep received during stages three and four is a necessary part of the restorative function of sleep.
Signs and symptoms of sleep and mental illness
People who have a sleep problem associated with mental illness are likely to display two sets of symptoms. The first set of symptoms is related to the mental disorder itself. These vary from condition to condition.
The second set of symptoms is related to the sleep problem. For example, patients with insomnia may experience any of the following symptoms:
- Increased anxiety at bedtime
- Tendency to spend too much time in bed
- Improvement in sleep patterns once the patient is removed from the typical sleep environment
Patients experiencing hypersomnia may exhibit symptoms such as:
- Fatigue or complete lack of energy
- Difficulty concentrating
- Tendency to fall asleep easily in low-stimulation situations
- Feelings of disorientation upon waking
- Decreased appetite
- Memory impairment
Diagnosis/treatment of sleep and mental illness
When patients have both a mental illness and a sleep problem, both should be addressed because each can precipitate or exacerbate the other. At times, treating the mental illness may result in a substantial improvement in the sleep problem, too.
For example, patients who are diagnosed with depression often benefit from a combination of psychotherapy and the use of antidepressant medications. Once the depression is successfully treated, the sleep problem may disappear.
However, if a patient’s complaints are primarily focused on sleep problems, one of two diagnoses may be made according to the criteria established by the American Psychiatric Association (APA): insomnia related to another mental disorder or hypersomnia related to another mental disorder.
Insomnia related to another mental disorder is diagnosed in patients who have difficulty falling asleep, remaining asleep or achieving restful sleep over a period of at least one month. The disturbance must be related to a type of mental health disorder and must cause significant impairment in social, occupational or other areas of functioning. It must be severe enough that it requires specific attention in addition to the attention paid to the mental disorder.
Finally, the insomnia cannot be better accounted for by another sleep disorder, and cannot be due to the use of certain substances or existence of certain medical conditions. This condition is diagnosed in between 35 and 50 percent of patients whose chronic insomnia is evaluated by a sleep study at a sleep disorder center, according to the APA.
Hypersomnia related to another mental disorder is diagnosed when over a period of at least one month, patients experience excessive sleepiness marked by prolonged sleep or daytime sleep that occurs nearly every day. The disturbance must be related to a mental health disorder and cause significant impairment in social, occupational or other areas of functioning. It also must be severe enough that it warrants specific treatment in addition to the attention paid to the mental disorder. The hypersomnia must not be more clearly related to another sleep disorder and must not be caused by simply not getting enough sleep, in order to meet the APA criteria.
Finally, the hypersomnia cannot be due to use of certain substances or existence of certain medical conditions. This condition is diagnosed in fewer than 5 percent of patients whose hypersomnia is evaluated by a sleep study at a sleep disorder center, according to the APA.
In some cases, symptoms of insomnia or hypersomnia may continue even after a mental illness has been treated effectively. In such situations, a new diagnosis of primary insomnia or primary hypersomnia may be made.
Finally, some sleep problems thought to be linked to a mental health condition are actually associated with physical illness. For example, patients with an overactive thyroid (hyperthyroidism) may experience chronic insomnia. Successfully treating the physical illness usually alleviates the associated sleep problem.
Questions for your doctor
Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to sleep and mental illness:
- What is causing my sleep difficulties?
- Do you suspect that my sleep problems are related to a mental illness?
- What type of mental illness do you suspect I have?
- How will you diagnose my mental illness?
- Do I have to prepare in any special way for the diagnostic tests?
- What are my treatment options?
- What are the side effects of these treatments?
- How soon after beginning treatment will I see improvement in my sleep?
- What happens if many of my symptoms improve, but my sleep problems remain?
- Are there other steps I can take to improve the quality of my sleep?