Sleep in the anxiety-related disorders: A meta-analysis of subjective and objective research

doi:10.1016/j.smrv.2020.101282

Sleep Medicine Reviews

Volume 51, June 2020, 101282

https://doi.org/10.1016/j.smrv.2020.101282 Get rights and content

Summary

Although sleep disturbance is implicated in psychopathology, its role in anxiety-related disorders remains unclear. The present meta-analysis characterizes sleep disturbance in anxiety-related disorders collectively and individually. Subjective measures of total sleep time and sleep continuity were included with objective measures. Results indicate a large effect for increased subjective sleep disturbance (g = 2.16), medium effects for decreased total sleep time (g = −.40) and sleep continuity (g = −.49), and a small effect for decreased sleep depth (g = −.20) in anxiety-related disorders compared to healthy controls. Each anxiety-related disorder exhibited a distinct sleep disturbance pattern, suggesting that sleep may facilitate identification of unique biopsychological underpinnings. Effects were not moderated by comorbid depression and were similar in magnitude to those found for depression. Sleep disturbances, particularly decreased sleep continuity, may be a key pathology in the anxiety-related disorders that could highlight novel etiological mechanisms and intervention targets.

Section snippets

Sleep assessment in anxiety-related disorders

Assessment of sleep disturbance in anxiety-related disorders can be broadly grouped into objective and subjective approaches. While objective assessment is unbiased and more precise, subjective measures are also critical, as polysomnography (PSG) indices explain limited variance in subjective sleep quality [10]. Thus, both objective and subjective methods are necessary to capture the sleep experience and may similarly be necessary to fully characterize sleep in anxiety-related disorders.

Sleep

Sleep disturbance in anxiety-related disorders

Although sleep disturbance is a transdiagnostic process, sleep is not a unitary construct, and sleep disturbances can take multiple forms (i.e., poor quality, insufficient duration, altered sleep architecture). Likewise, each anxiety-related disorder is unique in its primary symptoms. Given heterogeneity within both sleep and anxiety-related disorders, each disorder may have a unique sleep disturbance profile.

Selection of studies

A literature search was conducted using PsycINFO and PubMed to identify studies of sleep in anxiety-related disorders and MDD. Searches paired “sleep” with each of the following terms: generalized anxiety disorder; GAD; major depressive disorder; MDD; obsessive compulsive disorder; OCD; panic disorder; phobia; posttraumatic stress disorder; PTSD; social anxiety disorder; SAD; social phobia. The initial search yielded 10,648 articles. Fig. 1 shows that of these articles, 603 were read in full,

Study and sample characteristics

Of the studies analyzed, one included a mixed anxiety disorder sample, eight examined GAD, eight examined OCD, 11 examined PD, one examined specific phobia, 25 examined PTSD, four examined SAD, and 59 studies examined MDD. Mean age of participants in the included studies was 32.81 (SD = 4.1), ranging from 8.4 to 73.2, and study samples were 51.46% female, 69.15% Caucasian, 16.10% African American, 14.41% Hispanic/Latino, 9.65% Asian, and 9.07% other. 70.2% excluded participants taking

Discussion

The present meta-analysis characterized objective and subjective sleep in anxiety-related disorders, including the effects of age, gender, medication status, and comorbid MDD. Findings revealed moderate sleep disturbances in the anxiety-related disorders collectively, as well as in individual disorders. Consistent with previous meta-analyses, no two disorders shared the same sleep profile [8,42], suggesting that different facets of sleep disturbance may point to unique psychophysiological

Conclusions

Subjective sleep disturbance, TST and sleep continuity deficits are particularly robust in anxiety-related disorders, with minor evidence for diminished sleep depth. Lack of evidence for alterations in REM pressure distinguish the majority of anxiety-related disorders from MDD. In contrast, OCD is distinct from the anxiety-related disorders with evidence for increased REM pressure and intact sleep continuity. Further, the observed sleep effects were both comparable to those found in MDD and not

Funding

This work was supported by a National Institute of Mental Health F31 MH113271 and a Graduate Summer Research Award from Vanderbilt University awarded to the first author.

Conflicts of interest

The authors do not have any conflicts of interest to disclose.

Acknowledgements

The authors would like to thank Allison Booher, Olivia Lee, Sarah Jessup, Maria Sanin, and Yunshu Yang for assistance with data entry and Dr. Lance Riley for assistance with figure creation.

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Clinical ReviewSleep in the anxiety-related disorders: A meta-analysis of subjective and objective research

Summary

Section snippets

Sleep assessment in anxiety-related disorders

Sleep disturbance in anxiety-related disorders

Selection of studies

Study and sample characteristics

Discussion

Conclusions

Funding

Conflicts of interest

Acknowledgements

Psychiatr Clin

J Affect Disord

J Anxiety Disord

Sleep Med Rev

Clin Psychol Rev

Biol Psychol

Am J Geriatr Psychiat

Psychiatr Res

Sleep

J Anxiety Disord

Biol Psychiatr

Psychoneuroendocrinology

J Psychiatr Res

Biol Psychiatr

Psychiatr Res

Biol Psychiatr

Psychiatr Res

Neurosci Biobehav Rev

J Psychiatr Res

Psychol Bull

Sleep Med Rev

J Anxiety Disord

Neurosci Biobehav Rev

Sleep Med Rev

Sleep Med Clin

Clin Psychol Rev

Clin Neurophysiol

Psychiatr Res

Sleep Med Rev

Biol Psychiatr

Sleep Med

Behav Res Ther

Behav Ther

Brain Behav Immun

Psychoneuroendocrinology

Psychoneuroendocrinology

Sleep Med

Psychoneuroendocrinology

Biol Psychol

Clin Psychol Rev

J Psychiatr Res

J Anxiety Disord

Psychoneuroendocrinology

Sleep deprivation and the epigenome

Front Neural Circ

Memory encoding is impaired after multiple nights of partial sleep restriction

J Sleep Res

Impact of sleep restriction versus idealized sleep on emotional experience, reactivity and regulation in healthy adolescents

J Sleep Res

Sleep and mental disorders: a meta-analysis of polysomnographic research

Psychol Bull

Insomnia: neurophysiological and neuropsychological approaches

Neuropsychol Rev

The role of actigraphy in the study of sleep and circadian rhythms

Sleep

Recommendations for a standard research assessment of insomnia

Sleep

Clinical Review
Sleep in the anxiety-related disorders: A meta-analysis of subjective and objective research