Sleep anxiety: when worrying about sleep keeps you awake

How worrying about sleep may keep you awake

A 2023 systematic review of insomnia models notes that most people with insomnia name cognitive arousal, rather than bodily arousal, as the main cause of their sleep problems, and describes a “racing mind” as the crux of the insomnia experience.

The same review also describes sleep effort:

The same 2023 review describes sleep effort as often showing itself in actively attempting to sleep and in increasing the time given to sleep. The effort can be mental, such as suppressing mental stimulation, or behavioral, such as going to bed earlier.

Watching the clock may feed the same loop:

In the first of two experiments, good and poor sleepers asked to watch a clock while trying to fall asleep reported more worry before sleep and took longer to fall asleep than those asked not to. In the second, people with insomnia asked to watch a clock reported more worry and a longer time to fall asleep than on their own baseline night, and overestimated that time more than people asked to watch a digit display instead. The authors suggest clock-watching may fuel worry before sleep and help keep insomnia going.

1. Stop trying to sleep (paradoxical intention)

The idea is to drop the goal of sleeping. Get into bed, and instead of trying to sleep, let yourself stay awake.

The AASM guideline describes paradoxical intention as purposely doing the feared thing, staying awake, to reduce performance anxiety and the conscious intent to sleep.

Paradoxical intention asks you to stay awake as long as possible after getting into bed. The AASM guideline made no recommendation for or against it.

A 2022 meta-analysis of 10 trials found that paradoxical intention led to large improvements in key insomnia symptoms compared with passive comparison conditions and moderate ones in several central outcomes compared with active comparators, and that, compared with passive conditions, it greatly reduced sleep-related performance anxiety. Its authors say methodologically stronger studies are needed.

2. Do the worrying somewhere else

Bootzin’s 1972 paper set out to separate the bedroom at bedtime from everything but sleep: if a person wished to watch TV or to worry, he would have to do it somewhere other than the bedroom.

In practice: if you are lying awake worrying, get up and worry in another room, then come back when you feel sleepy. If thoughts keep running in circles at night, overthinking.today has a page on overthinking at night.

3. Give your mind something else to hold

In a one-night experiment with 41 people with insomnia, those taught to distract themselves with an interesting, engaging imagery task fell asleep sooner and had less frequent and less distressing thoughts before sleep than those given no instructions.

For a related technique, see cognitive shuffling. For more methods, each with its evidence, see how to fall asleep fast.

4. Look at the beliefs behind the worry

Unhelpful beliefs about sleep are what the cognitive part of insomnia therapy works on.

The AASM guideline describes cognitive therapy for insomnia as strategies such as psychoeducation, Socratic questioning, thought records and behavioral experiments, designed to change unhelpful beliefs about sleep that may support sleep-disruptive habits or raise performance anxiety about sleeping.

The American Academy of Sleep Medicine’s 2021 guideline strongly recommends multicomponent cognitive behavioral therapy for insomnia (CBT-I) for chronic insomnia in adults.

If you wake in the night and the worry starts then, see waking up at 3am; if you are lying awake right now, see what to do when you can't sleep.

When the anxiety is about more than sleep

The NHS lists the most common causes of insomnia as stress, anxiety or depression; noise; a room that is too hot or cold; an uncomfortable bed; alcohol, caffeine or nicotine; illegal drugs; jet lag; and shift work.

If you feel anxious or on edge most of the day, not only at bedtime, the anxiety itself deserves attention. Our sister site calmness.today has self-help for anxiety and panic, and the section below says when to talk to a doctor.