Influence of Emotional Instability and Anxiety on Sleep

in Stress Research and Insights

Fellow research review of: “Identifying and Addressing family Caregiver Anxiety” by Karen O. Moss, Colleen Kurzawa, Barbara Daly, and Maryjo Prince-Paul. 



  • The research was carried out to understand how emotional instability could contribute to anxiety disorder and its impact on sleep. The study was also carried out to differentiate emotional instability, both distinct and non-redundant constructs, at the neural, conceptual, and behavioral stages of analysis. Further studies proved that people with high Anxiety Sensitivity (AS) find it hard to regulate their emotions and thus have a higher risk of developing anxiety disorders. Dealing with anxiety through emotional self-regulation is possible if the proper emotion regulation methods are employed. 

  • myAir app suggests easy methods that an individual can use to monitor emotional progress. So far, myAir app has proven effective in monitoring progress in emotion regulation and the management of anxiety disorder. Contrary to most conceptions on suppressing emotions being bad for an individual, we have discovered that this concept does not hold entirely true. There are also positive results from the use of suppression tactics of emotion regulation. The results from the study of those with anxiety disorder proved to be positive as it helped manage the condition. 

  • The research discovered that regulatory measures help explain the increase in variance in anxiety disorder symptoms. A model derived from other studies was followed to understand better how emotional instability functions in the development and management of anxiety disorder. Emotion regulation helps regulate emotions that could affect sleep, e.g., anxiety, making it easier to fall asleep and get quality sleep without disruptions. 

  • Sleep also affects emotion regulation when individuals do not get enough quality sleep; they find it hard to control their emotions. They will be more sensitive to situations and will have their feelings burst out with less control. The myAir app plays the role of a consultant and helps manage anxiety and keep to the schedule made for practicing emotion regulation techniques.


The results obtained from this research suggest that the dysfunctional patterns of emotion regulation characterize individuals with anxiety disorders. However, the difficulties experienced in emotion regulation remain related to anxiety disorder symptoms even when the emotional reactivity methods, such as general anxiety and depression, are controlled. Emotional instability can also increase the effect of emotional reactivity on the symptoms of anxiety disorder. Accordingly, these results also complement the experimental research, demonstrating that emotion regulation techniques can increase or decrease fear and anxiety.


Emotional instability results from a series of biological-based psychological states brought on by changes associated with thoughts, environmental changes, behavioral responses, or some form of pleasure or displeasure. From a mechanical point of view, emotions can also be seen as either positive emotions or negative emotions.

Anxiety is an emotion characterized by a feeling of continuous worry, uneasiness, and fear of a specific situation. However, anxiety may be regarded as a normal biological human response, but it could lead to anxiety disorders when in excess.

Emotion regulation is the capability to control the range of emotion used in response to a specific situation or experience that is generally acceptable by the public while also being versatile in responding to different situations. Sometimes people cannot control their emotions due to chronic medical illnesses, which could be permanent, or some temporary body status like a drop in blood sugar or lack of sleep.

The role emotions play regarding sleep is largely overlooked, as people tend to forget its effects due to it being a normal biological response. The research was carried out to study the impact of regulating emotions. From the analysis, two main products of emotion regulation were observed on how emotions are experienced. The way the emotions of an individual experience can be affected by emotion regulation techniques in 2 ways. First, emotion regulation techniques involve the behavioral, subjective, and physiological indicators of emotions. Second, depending on which of the emotion regulation techniques is employed, there could be either an increase or a decrease in the way an individual responds emotionally.

It shows that reassessment could produce fewer self-reported adverse effects. Although behavioral suppression could increase physiological reactivity, it may not lead to a self-reported negative impact. Early facts show that the suppression of emotion could decrease the psychological arousal during emotion solicitation but could also increase said arousal to make amends for the emotion evocation. It is observed that the suppression of emotion could increase the adverse effects concerning reassessment. But when considering the risk factors concerning anxiety, such as anxiety sensitivity, the observed effects are not in agreement.

Generally, there are findings across the studies that provide evidence that regulation of emotion could control other negative emotions, such as anxiety, fear, disgust, etc. When emotions are not regulated or monitored, they could become excessive, leading to disorders, e.g., anxiety disorders. Previous to this research, it has been difficult to precisely relate the effects of emotion regulation on sleep.

Sleep plays a crucial role in maintaining overall emotional functioning, and emotion plays a vital role in maintaining overall mental health. Deprivation of sleep could lead to oversensitivity which reduces the control an individual has on their feelings, leading to various emotional disorders when not looked into and taken care of.

Emotion regulation, which is the ability of an individual to control their emotions, could also aid in sleep initiation. By learning to control their feelings, for example, emotions that could keep one awake at night, like anxiety, an individual would find it easier to fall asleep at night. Therefore it is safe to say that their relationship is bidirectional.


In light of available facts, it is possible to create a working model through which emotion regulation would benefit the development and management of anxiety disorders. Before this research, it was believed that suppressing an individual's nature could result in adverse effects and could increase the negative consequences later on in anxiety disorders.

An example of this case is an individual with high negative affect would be more likely to develop a phobia for dogs after getting bit by one, unlike an individual low in negative affect who a dog bites. The two main pieces of these models, such as dispositional factors and specific learning pathways, both of which explains emotional reactivity; meaning they present the possibilities that could result with an individual having heightened emotional reactivity either generally, i.e., positive or negative affect, or towards specific stimuli, i.e., specific learning pathways.

Programs for regulating emotions could involve either behavioral or emotional suppression. Negative re-appraisal could moderate fear responses' behavioral, physiological, cognitive, and behavioral outputs upon experiencing the required situation to trigger them.

First, the heightened fear when experiencing the required stimuli may function as a ‘reconditioning’ during this episode. The negative expectations are then strengthened to aid the individual to learn that they are indeed signals for danger. Second, the heightened fear could strongly motivate avoidance, hence preventing inhibitory learning. The individual will realize that feared stimuli are safe and that it is also safe to experience the emotional response caused by these stimuli.

In contrast, if programs for regulating emotions that involve behavioral or emotional suppression and negative re-appraisal are used chronically and rigidly, there may be two main consequences.

First, this response pattern would increase fear being experienced across different situations with the required stimuli and motivate an excess of avoidance of these different situations, hence maintaining the anxiety at all times.

Second, excessive avoidance, which is a result of these programs, would result in the impairment that defines anxiety disorders, such as impaired social relationships and work performance, and excessively enhanced fear could result in the higher impairing degree of emotional distress which is reported in individuals suffering from these disorders.


The evidence obtained from previous research highly suggests that people are suffering from an anxiety disorder, especially those suffering from Generalized Anxiety Disorder (GAD), show symptoms related to defective programs of emotion regulation.

People suffering from Generalized Anxiety Disorder (GAD) experience differently; they experience their emotions easily and fast with high intensity. People suffering from this have high emotional reactivity, making it harder for them to regulate their emotions. This heightened emotional reactivity also makes it difficult to understand and identify those who suffer from GAD.

Due to research in this field, emotion regulation is then defined as responding to one's emotion, not minding their nature and quality. In contrast, difficulties in emotion regulation consist of unacceptable responses to emotion. It could be inappropriate, inflexible, or maladaptive to the situation.

Other studies suggest that there is a relationship between maladaptive emotion regulation and panic disorders. For example, the fear of body sensations is characterized by avoidance, lack of emotional clarity, and emotional non-acceptance. Participants of this research who have a recent history of panic attacks give an account of using emotion avoidance strategies when exposed to either positive or negative emotion-evoking films.

High Anxiety Sensitivity (AS) has been discovered to be one of the core factors that could lead to panic disorders. But from recent studies, it is not certain that AS will lead to panic disorder, but it depends on how an individual regulates their emotions. In those with high AS, it was discovered that worry and anxious arousal were high where there is lower emotional distress acceptance. Agoraphobic cognitions, nervous arousal, and anxiety were also increased when few resources were available to control the effects properly. When there is high emotional expressiveness, agoraphobic cognitions are also heightened.


The results obtained from this research suggest that regulation of emotions could increase or decrease the emotional response, all depending on the method of emotion regulation being used. The effects of emotion regulation hold both on the cognitive-behavioral and neural extent. However, fear and emotion regulation are found to engage specific neural regions. Still, the regions for emotion regulation are different from the regions for fear during re-appraisal.

More importantly, these effects were discovered in the models that conditions fear that could provide a more naturally valid model of anxiety disorders. The results also illustrate the distinctness of the fear, anxiety, and emotion regulation constructs. Therefore, emotion regulation could appear to be a distinct construct that could causally influence the expression of fear and anxiety.

The typical indicators of fear, such as overt behavior, physiology, and verbal-cognitive processes, are loosely associated and multiply determined. Some research has shown that the region responsible for emotion, the amygdala, may mediate fear's behavioral, cognitive, and physiological indicators. Results also presented that emotion regulation methods could affect these same behavioral, verbal-cognitive, and physiological indicators.

However, the neural regions that moderate emotion regulation does not correspond with the amygdala activity during reappraisal. Accordingly, emotion regulation may also determine the difference among the three commonly used indicators for fear. These results seem to refer to previous concerns concerning the loose association of fear indicators. 

The current approach seems to show that emotion regulation can modulate the output of fear and maintain goal-driven behavior, and thus desynchrony is also expected under different circumstances. If the critical variable in anxiety disorder research is widely understood as these indicators of fear, then the theory would need to be taken into account for the influence of both fear and emotion regulation methods.

Finally, although specific emotion regulation methods have been associated with clear emotional repercussions, it is also unlikely that any emotion regulation method is generally ‘good’ or ‘bad’ in various contexts. Future research will be needed to clarify the boundary conditions under which the different techniques regulate emotional responses.


Original publication: Identifying and Addressing family Caregiver Anxiety

By Karen O. Moss, Colleen Kurzawa, Barbara Daly, and Maryjo Prince-Paul.

Published by PMC 2020

Footnote: No conflict of interest was recorded in this study


  1. Akkerman RL, Ostwald SK. Reducing anxiety in Alzheimer’s disease family caregivers: The effectiveness of a nine-week cognitive-behavioral intervention. American Journal of Alzheimer’s Disease and Other Dementias. 2004;19(2):117–123. doi: 10.1177/153331750401900202. [PubMed

  1. American Psychological Association. Anxiety. American Psychological Association Web site. Updated 2018. Accessed April 22, 2018. [PubMed]

  1. Anxiety and Depression Association of America. Understanding the facts: Depression. Updated 2016. Accessed April 22, 2018. [PubMed]

  1. Badger JM. Calming the anxious patient. American Journal of Nursing. 1994;94(5):46–50. [PubMed]

  1. City of Hope. Caregiver stresses and burdens Updated 2018. Accessed April 22, 2018. [PubMed]

  1. City of Hope. How to cope with anxiety. Updated 2017. Accessed April 23, 2018. [PubMed]

  1. City of Hope. Improving communication. Updated 2018. Accessed April 24, 2018. [PubMed]

  1. City of Hope. Managing stress. Updated 2018. Accessed April 22, 2018. [PubMed]

  1. City of Hope. Tools for caring for yourself. Updated 2018. Accessed April 24, 2018. [PubMed]

  1. Cukor D, Ver Halen N, Fruchter Y. Anxiety and quality of life in ESRD. Semin Dial. 2013;26(3):265–268. doi: 10.1111/sdi.12065 [PubMed

  1. Ducharme F Psychoeducational interventions for family caregivers of seniors across their life trajectory: An evidence-based research program to inform clinical practice. Advances in Geriatrics. 2014;2014:1–15. doi: 10.1155/2014/316203. [Google Scholar]

  1. Ferrell B, Wittenberg E. A review of family caregiving intervention trials in oncology. CA Cancer J Clin. 2017;67(4):318–325. doi: 10.3322/caac.21396 [doi]. [PubMed

  1. Ferrell BR, Grant M, Hassey Dow K Quality of-life model. City of Hope. 2001:1 [Google Scholar]

  1. Hamilton M The assessment of anxiety states by rating. Br J Med Psychol. 1959; 32:50–55. [PubMed

  1. Jillian LJ. Measures of anxiety. Arthritis Care Res. 2011;63(11). [Google Scholar]

  1. National Academies of Sciences, Engineering, and Medicine Families caring for an aging America. 2016. Washington, DC: The National Academies Press. doi:10.17226/23606. [Google Scholar]

  1. National Alliance for Caregiving AARP Public Policy Institute. Caregiver profile: The typical caregiver. 2015. Accessed October 20, 2017. [PubMed]

  1. National Cancer Institute. Caring for the caregiver. 2014. [PubMed]

  1. National Center on Caregiving. Caregiver Statistics: Demographics. Family Caregiver Alliance Web site. 2016. Updated 2018. Accessed October 20, 2017. [PubMed]

  1. National Comprehensive Cancer Network. Managing stress and distress. Updated 2018. Accessed April 25, 2018. [PubMed]

  1. National Institutes of Health. Patient-reported outcomes measurement information system: Anxiety. 2015.  [PubMed]

  1. National Institutes of Mental Health. Anxiety disorders. Updated 2018. Accessed April 15, 2018. [PubMed]

  1. Nipp RD, El-Jawahri A, Fishbein JN, et al. Factors associated with depression and anxiety symptoms in family caregivers of patients with incurable cancer. Annals of Oncology: Official Journal of the European Society for Medical Oncology / ESMO. 2016;27(8):1607–1612. doi: 10.1093/annonc/mdw205. [PubMed]

  1. Northouse L, Williams AL, Given B, McCorkle R. Psychosocial care for family caregivers of patients with cancer. J Clin Oncol. 2012;30(11):1227–1234. doi: 10.1200/JCO.2011.39.5798 [PubMed

  1. Northouse LL, Katapodi MC, Song L, Zhang L, Mood DW. Interventions with family caregivers of cancer patients: Meta-analysis of randomized trials. CA: A Cancer Journal for Clinicians. 2010;60(5):317–339. doi:10.3322/caac.20081. Accessed December 3, 2017. [PubMed]

  1. Northouse LL, Mood DW, Schafenacker A, et al. Randomized clinical trial of a brief and extensive dyadic intervention for advanced cancer patients and their family caregivers. Psychooncology. 2013;22(3):555–563. doi: 10.1002/pon.3036 [doi]. [PubMed]

  1. Park B, Kim S, Shin J, et al. Prevalence and predictors of anxiety and depression among family caregivers of cancer patients: A nationwide survey of patient-family caregiver dyads in Korea. Support Care Cancer. 2013;21(10):2799–2807. doi: 10.1007/s00520-013-1852-1. [PubMed]

  1. Pinar R, Afsar F. Back massage to decrease state anxiety, cortisol level, blood pressure, heart rate and increase sleep quality in family caregivers of patients with cancer: A randomised controlled trial. Asian Pac J Cancer Prev. 2015;16(18):8127–8133. [PubMed

  1. Sklenarova H, Krumpelmann A, Haun MW, et al. When do we need to care about the caregiver? supportive care needs, anxiety, and depression among informal caregivers of patients with cancer and cancer survivors. Cancer. 2015;121(9):1513–1519. doi: // [PubMed]

  1. Spielberger CD, Gorsuch RL, and Lushene. RE Manual for the state-trait anxiety inventory. Palo Alto, CA: Consulting Psychologists Press; 1970. [Google Scholar]

  1. Steer RA, Beck AT. Beck anxiety inventory In: Zalaquett CP, Wood RJ, eds. Evaluating stress: A book of resources. Lanham, MD: Scarecrow Education; 1997:23–40. [Google Scholar]

  1. Sun V, Grant M, Koczywas M, et al. Effectiveness of an interdisciplinary palliative care intervention for family caregivers in lung cancer. Cancer. 2015;121(20):3737–3745. doi: 10.1002/cncr.29567. [PubMed 

  1. Sun V, Kim JY, Irish TL, et al. Palliative care and spiritual well-being in lung cancer patients and family caregivers. Psycho-Oncology. 2016;25(12):1448–1455. doi: 10.1002/pon.3987. [PubMed]

  1. Wittenberg E, Buller H, Ferrell B, Koczywas M, Borneman T. Understanding family caregiver communication to provide family-centered cancer care. Seminars in Oncology Nursing. 2017;33(5):507–516. doi: // [PubMed