The Relationship Between Social Anxiety and Insomnia

Worrying about social fears may keep you up at night.
Getty / milos-kreckovic

Insomnia is a sleep disorder that sometimes co-exists with social anxiety disorder (SAD). In simple terms, insomnia refers to trouble falling asleep or getting enough sleep.

While most people have trouble falling asleep from time to time, those with chronic insomnia have trouble sleeping more than three nights a week for three months or more. Often, insomnia occurs in people who have another mental health disorder.

If you're dealing with social anxiety disorder, you might lay awake at night worrying about the events of the day, perhaps wondering if you embarrassed yourself at school or at work. In turn, you might think about the next day and worry about that as well, dreading the thought of having to talk to classmates or coworkers who might notice your anxiety.

It's not unusual for such thoughts to continue circling through your head like a broken record and make sleeping difficult. After tossing and turning for awhile, you might fall asleep only to wake up a few hours later and stare at the clock for the rest of the night until the alarm goes off.

Does the above description sound at all like you? Individuals with SAD are prone to problems with insomnia because of their tendency to worry at night. Insomnia can lead to problems with daytime functioning and poor quality of life, including causing trouble for you in your work and social relationships.

Finally—just like SAD, insomnia tends to go unreported and untreated. Patients forget to tell their doctors about their sleep problems, and doctors forget to ask.

How Do You Know If You Have Insomnia?

People with insomnia have trouble getting enough sleep and feel tired as a result. Trouble getting enough sleep can result from any of the following:

  • taking too long to fall asleep
  • waking up frequently through the night
  • waking up at night or too early in the morning and not being able to fall back asleep

If any of these issues is a problem for you, and you also live with social anxiety, it is possible that your difficulty sleeping is related to your issues with anxiety.

How Is Insomnia Assessed?

Insomnia may be assessed using a self-rating sleep questionnaire. The most widely used and validated questionnaire for this purpose is the Pittsburgh Sleep Quality Index. In this questionnaire, you will be asked about your sleep quality, sleep problems, and more in the past month.

Another tool to assess insomnia is a sleep log or diary. Completion of one of these tools allows your doctor to analyze your nightly sleep patterns, such as when you went to bed, fell asleep, and woke up. Typically you would complete a log for a period of two weeks.

If you have severe sleep problems, referral to a sleep laboratory for assessment might be warranted.

Treatments for Insomnia

Insomnia can be treated with medication, therapy, or a combination of the two.

Cognitive-behavioral therapy for insomnia (CBT-I) has been shown to be highly effective. It has also been shown to be as effective as medication for short-term treatment of chronic insomnia.

However, only about 1 percent of patients with chronic insomnia receive this type of therapy.

In a case study, brief cognitive behavior therapy for insomnia (CBT-I) was evaluated.

  • Five sessions were given on a weekly basis.
  • Treatment involved psychoeducation, sleep restriction therapy (reducing time spent in bed), stimulus control (re-associating your bedroom with sleep), and cognitive restructuring (developing more helpful thoughts about sleep).
  • All targeted sleep parameters showed improvement.
  • Gains were maintained at 9 months after treatment.
  • Sleep-related anxiety and dysfunctional beliefs/attitudes about sleep were reduced.
  • Results suggested that brief CBT-I could be incorporated into treatment for SAD for people who have trouble with insomnia.

However, medication is generally the primary treatment for insomnia because it works quickly, usually within days to a week. There are many types of drugs used in the treatment of insomnia. Here are some common categories:

  • Nonbenzodiazepines (e.g., eszopiclone)
  • Benzodiazepines (e.g., estazolam)
  • Tricylic antidepressant (e.g., low-dose sinequan)
  • Melatonin agonist (ramelteon)

While alternative treatments for insomnia such as bright light, acupuncture, and yoga may hold some appeal, there has not been consistent evidence to support their effectiveness.

Is There a Relationship Between Social Anxiety and Insomnia?

In a nationally representative cross-sectional survey, it was shown that individuals with comorbid (meaning that they had both) mood and anxiety disorders, or mood or anxiety disorders alone, had significantly higher rates of severe insomnia compared to three other groups.

For those with both mood and anxiety problems, reports of severe insomnia in the past year were related to increased days of impairment, or simply, days when they did not function well.

In another study using an undergraduate sample of almost 200 students (some of whom were grouped as having clinical anxiety symptoms), it was shown that social anxiety was related to increased symptoms of insomnia.

People with SAD were more dissatisfied with their sleep, experienced more impairment because of their sleep problems, and were distressed about their sleep problems.

However, it was also shown that depression may have played a role in mediating the relationship between social anxiety and insomnia. In other words, there seems to be a link between SAD and insomnia, but it is possible that the co-occurrence of depression could be an important factor contributing to the insomnia.

Finally, in a study of 30 individuals with generalized SAD and 30 matched healthy controls, it was found that patients with generalized SAD showed poorer sleep quality, longer sleep latency (time to fall asleep), more frequent sleep disturbance, and more severe dysfunction during the day.

Those with a lifetime history of major depression did not show different findings compared to those without this diagnosis. These results suggest that in particular, the generalized form of SAD may be related to sleep disturbances, regardless of whether depression is also an issue.

Other Causes of Insomnia

There are many potential causes of insomnia that are not related to having an anxiety disorder. A doctor will need to rule these out before beginning any sort of treatment. Below is a list of other potential causes or contributors to insomnia:

  • sleep apnea (a problem in which you stop breathing for brief repeated periods)
  • restless legs syndrome
  • cardiovascular disorders (e.g., congestive heart failure)
  • pulmonary disorders (e.g., emphysema)
  • thyroid disorders
  • GI disorders (e.g., acid reflux)
  • neurological disorders (e.g., pain syndromes)
  • medications for medical and psychiatric disorders (e.g., SSRIs for anxiety/depression, amphetamines for ADHD, pain medication)
  • psychostimulants (e.g., ephedrine in cold medication)
  • bronchodilators
  • caffeine or alcohol use

Tips to Cope With Insomnia When You Have SAD

In addition to receiving treatment for your social anxiety, there are steps you can take on your own to help improve your insomnia. Monitoring your sleep hygiene is something that everyone can do. Good sleep hygiene might involve doing the following:

  • Limit daytime naps.
  • Limit late night snacks or meals.
  • Avoid rigorous exercise immediately before bed.
  • Avoid watching TV in bed.
  • Reduce light and noise in the bedroom.
  • Go to bed at a regular time every night.
  • Wake up at a set time every morning.
  • Follow a bedtime routine that allows you to relax.
  • Don't lie in bed awake for more than 5 to 10 minutes. Get up and worry (if you must—ideally get a handle on your worrying too!) somewhere else until you feel sleepy. This limits your association of lying awake worrying with your bedroom..
  • Limit caffeine and alcohol.
  • Set the temperature to your bedroom at a comfortable level, preferably on the cool side.
  • Buy a comfortable mattress if you don't already have one.
  • Hide the clock if you tend to watch it.

A Word From Verywell

If you suffer with both insomnia and social anxiety disorder, successful treatment of your insomnia could make your anxiety disorder more responsive to treatment as well. Be sure to mention your trouble sleeping to your doctor, so that this separate problem can be treated directly.

​Sources:

Buckner JD, Bernert RA, Cromer KR, Joiner TE, Schmidt NB. Social anxiety and insomnia: the mediating role of depressive symptoms. Depress Anxiety. 2008;25(2):124-130. doi:10.1002/da.20282.

Psychiatric Time. Treatment of Insomnia in Anxiety Disorders.

Raffray T, Bond TLY, Pelissolo A. Correlates of insomnia in patients with social phobia: role of depression and anxiety. Psychiatry Res. 2011;189(2):315-317. doi:10.1016/j.psychres.2011.03.004.

Soehner AM, Harvey AG. Prevalence and functional consequences of severe insomnia symptoms in mood and anxiety disorders: results from a nationally representative sample. Sleep. 2012;35(10):1367-1375. doi:10.5665/sleep.2116.

Tang NKY. Brief CBT-I for insomnia comorbid with social phobia: A case study. Behav Cogn Psychother. 2010;38(1):113-122. doi:10.1017/S1352465809990488.

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