Anxiety and Sleep
Getting nervous or worried is completely normal, but for a significant number of people -- nearly 40 million adults in the United States, or roughly 18% of the population -- anxiety doesn’t relent and can negatively affect nearly every aspect of their well-being.
When this anxiety is overwhelming, a person may have an anxiety disorder. Anxiety disorders can take many forms and represent a complex set of conditions. Anxiety and sleeping problems frequently occur together: research indicates that anxiety harms sleep and that lack of sleep can contribute to anxiety.
This guide helps to untangle this topic and covers what anxiety is, the different types of anxiety disorders, how these conditions impact sleep, and tips for improving sleep and managing anxiety.
What is Anxiety?
Anxiety is a feeling of worry, nervousness, or fear, and in many situations, it is completely normal. In anxiety disorders, though, these feelings do not go away and may worsen with time, leading to negative impacts on a person’s emotional and physical health.
The term anxiety disorder is used to describe multiple specific types of anxiety. The causes, symptoms, and treatments may vary, but for all the types, anxiety can interrupt a person’s everyday life and ability to manage work responsibilities and social and family relationships.
In general, people with anxiety disorders experience these negative feelings most days for a period of 6 months or longer. Symptoms of anxiety disorders include irritability, panic, a sense of impending danger, heightened heart rate, quickened breathing, excessive sweating, trembling, fatigue, gastrointestinal issues, problems concentrating, and difficulty sleeping.
The relationship between sleep and anxiety is complex. People with anxiety disorders frequently struggle with various aspects of sleep. They may have a harder time falling asleep, staying asleep, and getting sleep that truly feels restful. Concerns about sleep can become a source of anxiety, causing heightened stress when trying to go to bed. This fearful anticipation can itself become a contributor to sleeping problems.
At the same time, lack of sleep may influence how a person experiences anxiety. The causes of anxiety disorders are multifaceted, and it is difficult to say exactly to what extent poor sleep influences a person’s risk of this condition. That said, research in 2013 at the University of California-Berkeley found that lack of sleep activates parts of the brain associated with anxiety and that this effect is greater in people who are prone to worrying.
Diagnosis of anxiety disorders is done in consultation with a doctor and mental health professional. A doctor can determine if the symptoms are being caused by any other condition, and a psychiatrist can assess symptoms to determine whether they meet the criteria for generalized anxiety disorder (GAD) or another type of anxiety.
Anxiety disorders do not always have a clear-cut cause. Various risk factors influence a person’s chances of being affected by anxiety. Genetics and environmental factors may both play a role in these conditions.
Some known risk factors for anxiety include childhood shyness, exposure to stressful or traumatic events, and a history of anxiety in family members. In some cases, physical ailments, including thyroid, lung, and heart problems, can trigger anxiety, and use of or withdrawal from certain substances, like amphetamines, alcohol, or caffeine, may contribute to a person’s risk.
Types of Anxiety
Coping with anxiety is difficult, and anxiety disorders are often misunderstood.
Not all people experience anxiety disorders in the same way. The causes, symptoms, and treatments can vary, and this has led to subcategories to differentiate specific types of anxiety. In addition, because they are distinct, they can have different effects on sleep.
To provide more background and nuance about anxiety, the following section offers details about the most common types of anxiety disorders.
Generalized Anxiety Disorder (GAD)
Generalized anxiety disorder is marked by feelings of worry or fear. This is not a distinct phobia but an overarching sense of worry that does not go away even if stressors are reduced. Anxiety can be related to or provoked by various things including work obligations, relationships, finances, and health.
Symptoms of GAD include having these fearful feelings and can also involve a faster heart rate, stomach problems, hyperventilation, fatigue, and problems focusing. The condition is diagnosed if a person has 3 or more symptoms that last for 6 months or longer.
An estimated 6.8 million adults in the United States are affected by GAD. The condition is nearly twice as common in women, and many people who suffer from anxiety experience depression as well.
For many people, GAD begins with moderate feelings of worry or danger. However, people affected by this condition may feel trapped in a cycle of anxiety -- worrying about worrying itself -- that can worsen symptoms. The severity of GAD can vary with time, but if often affects a person’s behavior. For example, someone may completely avoid situations that could potentially elicit anxiety.
Treatment of GAD frequently involves the use of cognitive behavioral therapy (CBT) to change how a person perceives and relates to worry. CBT may be combined with other interventions ranging from medications to relaxation techniques to adjust a person’s approach to their fears and concerns.
Obsessive Compulsive Disorder (OCD)
As the name indicates, OCD relates to obsessions and compulsions. Obsessions are mental and involve thoughts or images that provoke anxiety. Compulsions are actions taken to try to control or eliminate those negative thoughts. In any given person, these obsessions and compulsions can be multifaceted and may not be directly related.
Examples of obsessions include fears of germs, worries about losing things, recurring thoughts about traditionally taboo subjects, or the desire for precise order or symmetry. Examples of compulsions include frequent washing or cleaning, repeatedly checking things, repeatedly counting, meticulous organizing, or hoarding unneeded items.
The cause of OCD is unknown although there can be a genetic relationship as the condition appears to be more common in some families. The condition frequently begins younger in life with up to a third of cases beginning in childhood or teenage years. OCD affects roughly 2.2 million adults in the United States and it is as common in men as in women.
Frequent obsessions and compulsions are the primary symptom of OCD although a person with OCD may also have motor or vocal tics. If the obsessions and compulsions are frequent, time-consuming, and disruptive to a person's life, they may meet the clinical criteria for diagnosing OCD.
Treatment typically includes CBT and often involves Exposure and Response Prevention (EX/RP), a strategy that involves gradual exposure to obsessions to reduce the anxiety associated with them. Medications are also sometimes used to help treat OCD.
Panic disorder is a condition characterized by sudden and severe panic attacks. Panic attacks are episodes of intense fear and can include various symptoms. These can be both mental and physical including feelings of dizziness, shortness of breath, chest pain, heart palpitations, and gastrointestinal distress.
Panic attacks can occur at any time and can be unexpected or expected. In other words, they may or may not be related to a specific trigger.
Panic attacks are extremely distressing. As a result, people who experience them may worry about having another attack. This can lead to broader anxiety and/or disruptive changes in behavior to try to prevent panic attacks.
Experiencing panic attacks alone does not constitute panic disorder. It is when a person has had repeated panic attacks and has experienced anxiety or behavior changes related to them that they can be clinically diagnosed with panic disorder.
It is estimated that panic disorder affects around 6 million adults in the United States. It is more common in women than in men, and it often begins in the teenager years or in early adulthood. To date, there is no clearly identified cause of panic disorder or panic attacks. It may have a genetic component based on observed family histories, but research is still ongoing to identify specific causes.
Treatment for panic disorders generally involves counseling and can include medication as well. CBT may be used to try to change how a person reacts when a panic attack begins. Over time, this may reduce both the frequency and severity of these attacks.
Post-Traumatic Stress Disorder (PTSD)
PTSD is a mental health condition that many people experience after they have gone through a stressful or traumatizing situation or event. PTSD can begin shortly after a traumatic event has occurred or can arise many years later.
PTSD affects an estimated 7.7 million adults in the U.S. The most common triggers for PTSD include rape, childhood sexual abuse, and serving in combat. The condition is more common in women than men.
The symptoms of PTSD include negative feelings, reliving the traumatic event in nightmares or flashbacks, avoiding potential triggers, and hyperarousal, which is a sense of being perpetually on alert. These feelings can have both mental and physical effects, and insomnia is also a commonly reported symptom of PTSD. Overall, symptoms may not be consistent and can vary over time in both their severity and frequency.
Treatment for PTSD frequently involves the use of CBT which may involve confronting or reframing the experience of trauma. It can include coping and relaxation strategies and may be combined with medications as part of an overall treatment plan.
Social Anxiety Disorder
Social Anxiety Disorder (SAD) involves extreme shyness and self-consciousness in situations involving other people. SAD is distinct from just being timid. Some people are quieter or are more likely to get nervous in social situations, but with SAD, this concern becomes overwhelming and interferes with emotional health and social relationships.
Symptoms of SAD include feelings of significant discomfort in social settings. That discomfort may lead to avoidance of these settings altogether. Fears may be specific to certain people or situations or may be general. When these feelings are persistent and disrupt everyday activities, they may be diagnosed as SAD.
SAD can produce physical symptoms as well. These include sweating, shaking, blushing, a racing heart rate, chest or stomach pains, nausea, headaches, vertigo, and shortness of breath. People with SAD may have limited social connections and may turn to alcohol or drugs to attempt to blunt their social anxiety. SAD can be present along with selective mutism, an anxiety disorder that involves not speaking in certain situations.
SAD affects 15 million adults in the U.S. but often begins in childhood. The average age of onset is around 13 years old, and the condition is as common in men as in women. The exact cause is unknown, but researchers believe that it likely involves genetic and environmental factors.
Treatment for SAD can include psychotherapy and/or medications. CBT is frequently employed to help people with this condition change their relationship to different interpersonal contexts. This can work to mitigate fears and enable a healthier orientation toward social interaction.
Phobias are intense and often disabling fears of a particular thing or situation. Specific phobias are believed to affect around 19 millions adults in the United States, but they frequently start in childhood. The average age when specific phobias begin is 7 years old.
It is normal to be afraid of certain things, and having these fears does not constitute a specific phobia. With specific phobias, fears are extreme and can provoke profound anxiety. Exposure to what is feared, or even just thinking about it, may even provoke panic attacks. The fact that the fear may be irrational is irrelevant; a person with a specific phobia cannot control the fear regardless of how unlikely the risk may be.
This category of anxiety disorders is typically broken into three types.
- Agoraphobia involves fear of being in places where leaving is either extremely difficult or embarrassing. Examples include open spaces, enclosed spaces, public transportation, being in large crowds, or going outside of home alone. People with agoraphobia typically have major fears of two or more of those places.
- Social phobia is the fear of social interactions and is also known as Social Anxiety Disorder that was described in the previous section.
- Specific phobias involve fears of a particular thing such as spiders (arachnophobia), snakes (ophidiophobia), or heights (acrophobia).
People with these phobias often go to great lengths to avoid any potential exposure to them, and this may interfere with daily living including work responsibilities and social relationships.
There is no clearly identified cause of specific phobias. Treatment depends on the specific person and phobia but commonly includes CBT and types of gradual exposure therapy. Medications and strategies for relaxation can also be part of a treatment plan for specific phobias.
How Anxiety Affects Sleep
Anxiety and not sleeping well are frequently co-existing problems. Knowing which of these problems is the true cause can be a challenge. Most often, this is a “chicken-and-egg” situation in which anxiety and sleep problems trigger and reinforce one another.
The prevalence of sleep problems among people with anxiety disorders is extremely high. Among people with Generalized Anxiety Disorder, insomnia is found in around 50% of patients. In U.S. veterans with PTSD who have served in recent foreign wars, rates of insomnia are reported to be between 90% and 100%. Sleep disturbances can be major problems in patients with OCD, SAD, and panic disorder as well.
Anxiety poses significant barriers to consistent, quality sleep. Virtually all sleep experts acknowledge the importance of sleep hygiene for getting a good night’s rest. This hygiene involves habits and environments that promote healthy sleep. Many aspects of sleep hygiene involve creating calmness and comfort so that you can smoothly drift to sleep, but anxiety directly disrupts that kind of sleep-permissive context.
Excessive worrying can keep the mind racing even as a person is trying to relax and go to bed. With preoccupations flooding their thoughts, it may be impossible for a person to get to sleep in the first place. If they wake up in the middle of the night, worries may come rushing back, making it difficult to stay asleep through the night. Sleeping in fits and starts can layer frustration and fatigue on top of anxiety.
For people with PTSD or specific phobias, nightmares, flashbacks, or other visualizations can interrupt sleep and may make someone afraid of going to sleep at all. This reflects a broader challenge of anticipatory anxiety in which just thinking about sleep difficulties like insomnia and nightmares makes a person even more nervous about bedtime.
In some cases, anxiety disorders coexist with other mental health conditions like depression that are frequently associated with insomnia. Anxiety can coexist with physical ailments as well, and some of these conditions can exacerbate sleeping problems. For example, many veterans with PTSD have chronic pain that prevents getting comfortable enough to sleep well.
People with anxiety and insomnia commonly turn to alcohol or other controlled substances to try to self-medicate. Unfortunately, this can backfire in several ways. While alcohol or sedatives may help someone fall asleep, they can reduce the depth of sleep by interrupting the sleep cycle. They can affect breathing at night and increase a person’s risk of developing obstructive sleep apnea. And they can be habit-forming, creating a dependence that makes sleep even more difficult when their use is stopped.
At the same time, sleeping problems may contribute to problems with anxiety. Regular sleep deprivation has widespread effects on the mind and body that can reduce overall well-being and mood. Research has shown that this can have a direct influence on anxiety.
In a study at UC-Berkeley, it was found that lack of sleep triggered a 30% increase in anxiety. This is believed to be because reduced sleep generates more activity in parts of the brain that are associated with nervousness and fear. By accelerating these types of thoughts, sleeping problems appear to heighten the risk of anxiety in precisely the people who may already be predisposed to it. Lack of sleep may make feelings of anxiety and attendant symptoms more severe and more frequent.
While it may be impossible to say exactly which comes first among sleep problems and anxiety, it is clear that they can be mutually reinforcing in a negative way, and it comes as no surprise that anxiety and not sleeping are commonly described as co-occurring.
At the same time, the relationship between anxiety and sleep leaves room for hope because taking steps to address one can have positive effects on the other. It may take time and focused effort, but there are strategies that can reduce anxiety and improve sleep.
How to Get to Sleep When You Have Anxiety
Anxiety and insomnia can be challenging and frustrating. There is no simple therapy that resolves these problems for everyone, and it may take trial-and-error to find the approach that works best for you.
Diagnosis and treatment of anxiety disorders almost always requires working with a health professional who can review your situation and develop a plan to improve it.
If you have noticed symptoms of anxiety, talk with your family doctor. Your doctor can make sure that those symptoms are not being caused by an underlying health problem, and they can also try to identify other causes of any sleeping problems that you may have.
Working with a psychiatrist plays an integral role in coping with anxiety. A trained counselor can put a name to your specific struggles and reassure you that you’re not the only one with this kind of condition. Additionally, they can collaborate with you to address anxieties directly.
While there is no single treatment plan that works for everyone, CBT can be a great help to many people affected by anxiety. A psychiatrist can guide you in this type of therapy and develop specific steps for managing and reducing anxiety. Some counselors are trained in CBT for insomnia (CBT-I) that can integrate similar methods into improving sleep as well.
Improving Sleep Hygiene
Sleep hygiene encompasses your sleep environment and your sleep-related habits. Improving sleep hygiene can help get you primed for sleep and may lessen anxiety when you go to bed. Sleep hygiene is frequently an emphasis of CBT-I.
Creating A Positive Sleep Environment
Step one in improving sleep hygiene is creating a context that is permissive for sleep.
- Get a great mattress and pillow: deep sleep is hard if you aren’t comfortable, and a supportive mattress and pillow also keep your body supported to reduce aches and pains.
- Find bedding that suits you: every sleeper has different needs. For example, you may sleep hot or may prefer your bed warm and cozy. Finding sheets and comforters that fit you will go a long way to putting you in the mood for sleep each night. You can also consider using a weighted blanket.
- Shut out distractions: excess sound and light and sound can interfere with diligent efforts to get to bed. Try a white noise machine or earplugs to block out disruptive noise, and use blackout curtains or an eye mask to remain in darkness. Avoid using mobile phones, laptops, or tablets for at least half an hour before bed.
- Find the right temperature: the optimal thermostat setting is subjective, but most people do best sleeping in a cooler bedroom.
- Make it smell nice: if you’re smell sensitive, consider essential oils to freshen up your bedroom scent. Some smells, like lavender, may promote calmness.
Developing Healthy Sleep Habits
Healthy sleep habits can signal to your mind and body that it’s time for bed and help you ease more comfortably into sleep.
- Establish a routine: almost all sleep experts recommend trying to follow a regular sleep schedule. This includes going to bed and waking up at the same time each day and even on weekends. In the time leading up to your bedtime, follow the same steps each night such as brushing your teeth, meditating, having a cup of warm tea, or whatever series of steps best prepares you to go to bed.
- Stop clock-watching: once you’re in bed, try to avoid constantly checking the clock. This can just create additional anxiety if you struggle to fall asleep immediately.
- Limit activities in bed: your bed should be for sleeping and for sex only. This builds the association in your mind of getting into bed with going to sleep rather than with other activities -- like eating or watching TV -- that may keep you awake.
Practicing Relaxation Techniques
Sometimes it’s when you just want your mind to shut down for sleep that anxieties and negative thoughts start to swell up. When that happens, relaxation techniques can counteract the cycle of negative thoughts and sleeplessness.
Remember that not all of these techniques work for everyone. The important thing is to find the methods that are easiest and most effective for you to apply in your own circumstances.
- Meditate: there are many types of meditation that can help calm the mind, and you don’t have to reach guru-levels of meditating for it to be beneficial. If you’re not sure where to start, a psychiatrist can help, or you can check out some smartphone apps built for meditation.
- Journal or make a list: if your mind is being overrun by thoughts, it may be helpful to put them down on paper. Write an entry in a journal or jot down the key things you want to make sure that you remember.
- Play music: music can be supremely relaxing, and you may find it helpful to keep a playlist just for finding tranquility or for going to bed.
- Try the tense and relax method: progressive muscle relaxation involves tightening and releasing muscles in a gradual process coordinated with deep breathing.
- Clean: some people find that doing some light cleaning or tidying up is an opportunity to relax while getting organized. You can also do this while listening to calming music or focusing on deep breathing.
- Exercise: being active contributes to health in myriad ways. Light exercise may help relieve stress and anxiety. Physical activity can play a role in reducing insomnia and promoting good sleep.
Learn More About Anxiety and Sleep
Information About Anxiety
MedlinePlus: Portal for Information on Anxiety. An introduction to anxiety from MedlinePlus, a service of the U.S. National Library of Medicine. It includes links to assorted evidence-based resources on this topic.
Merck Manual: Overview of Anxiety Disorders. This article by Dr. John Barnhill from Weill Cornell Medical College covers the causes, symptoms, and treatment of anxiety.
The American Psychiatric Association (APA). The APA is a leading organization of trained mental health professionals, and their website has resources for patients and families including a tool to find a counselor in your area.
American Academy of Adolescent and Childhood Psychiatry: Resources for Family & Youth. This page offers links to help find a psychiatrist and other resources for young people affected by anxiety and their families.
The Mayo Clinic: Anxiety. This page from the Mayo Clinic delivers additional information about the types of anxiety and the signs, causes, and treatments for these conditions.
A History of Anxiety: From Hippocrates to DSM by Marc-Antoine Crocq, MD. This academic article in the journal Dialogues of Clinical Neuroscience reviews the history of how anxiety has been understood and classified.
National Institute of Mental Health (NIMH): Anxiety Statistics. This page offers data about the prevalence of anxiety disorders among different populations in the United States with links to in-depth data sources.
Effect of Cognitive Behavioral Therapy for Anxiety Disorders on Quality of Life: A Meta-Analysis by Hofmann, Wu, and Boettcher. This article from the Journal of Consulting and Clinical Psychology analyzes 44 different studies regarding CBT-I and anxiety.
Chronic Insomnia as a Risk Factor for Developing Anxiety and Depression by Neckelmann, Mykletun, and Dahl. An article from the journal Sleep about the relationship between insomnia and anxiety and depression.
Introduction to Anxiety and Child Anxiety Disorders. This video features an explanation of how anxiety can affect children from Eli Lebowitz, PhD, an Assistant Professor at the Yale Child Study Center.
The Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline. This is a free phone-based service to provide support and referrals to people affected by mental illness. It is available 24 hours a day, 7 days a week, 365 days a year.
Anxiety and Depression Association of America (ADAA): Support Groups. This page provides listings of anxiety support groups in the U.S. and Canada and provides links to learn more about starting your own support group.
National Alliance on Mental Illness (NAMI): Support. This organization describes how to get help and offers information for both patients and family members of people affected by anxiety.
The National Center for PTSD: Finding Help. For people with PTSD, this page offers various links to find appropriate resources including for self-help and professional help.
The National Veterans Foundation. Many people with PTSD are veterans, and this non-profit, non-government organization coordinates various programs to assist them.
Obsessive Compulsive Disorder (OCD)
NIMH: Obsessive Compulsive Disorder. The NIMH site for information on OCD provides an introduction to this condition including details about symptoms, causes, treatment, and ongoing research.
International OCD Foundation: Support Groups. This non-profit organization offers a range of information to people with OCD including this listing of support groups and other tips for coping.
Social Anxiety Disorder
The Social Anxiety Association. This group helps connect and empower people who suffer from social anxiety disorder. Resources include a regular mailing list and a Facebook community.
Living with Panic Attacks by Margarita Tartakovsky, M.S. This article from PsychCentral provides perspective on panic attacks and gives an overview of some of the most common treatments.
Harvard University: Sleep Health and Education. This website from the Sleep Medicine program at Harvard delivers in-depth and evidence-based information about a broad range of sleep-related topics.