Sleep anxiety is the everyday name for worry about sleep, or for anxiety that is loudest at bedtime, and the research points to a loop between the two. Sleep disruption is a recognised feature of all anxiety disorders, and in one study even modest night-to-night reductions in sleep predicted more anxiety the next day. [ben-simon-2020] This guide covers how the loop works, what the evidence says about breaking it, and what to try tonight. Our overview of anxiety covers the wider picture.
What is sleep anxiety?
Sleep anxiety is worry about sleep itself, or anxiety that gets loudest once the lights are off. It covers dreading the night ahead, watching the clock, and lying awake rehearsing tomorrow. It is a description of an experience and not a test result, so a doctor would ask whether insomnia, an anxiety disorder or both fit what is happening.
Researchers who study bedtime worry describe it, including worry about unfinished tasks, as a significant contributor to difficulty falling asleep. [scullin-2018] That matters because it makes sleep anxiety a specific, workable target and not a character flaw.
How do anxiety and poor sleep feed each other?
Each makes the other worse, according to the research: sleep loss raises next-day anxiety, and long-term studies show insomnia predicting anxiety disorders later. Sleep disruption is also a recognised feature of all anxiety disorders, so the pull runs in both directions. [ben-simon-2020]
Ben Simon and colleagues reported that the anxiety that follows sleep loss is linked to impaired activity in the medial prefrontal cortex and in its connections with limbic regions, which are deeper brain areas involved in emotion. They also reported that non-REM slow-wave sleep had a calming effect on those same networks, and that even modest night-to-night reductions in sleep across the population predicted day-to-day increases in anxiety. [ben-simon-2020]
The other direction comes from long-term follow-up. Hertenstein and colleagues pooled 13 longitudinal studies and found that insomnia at the start predicted a later anxiety disorder, with an odds ratio of about 3.2 across six samples. It also predicted depression, with an odds ratio of about 2.8 across ten samples. [hertenstein-2019] An odds ratio is not a risk, the anxiety figure rests on only six samples, and the authors note that the observed pattern does not allow causal conclusions.
| Study | What it found | What it cannot tell you |
|---|---|---|
| Ben Simon et al., 2020 | Modest night-to-night drops in sleep predicted more anxiety the next day | How your own anxiety will respond to one short night |
| Hertenstein et al., 2019 | In 13 long-term studies, insomnia predicted later anxiety (odds ratio about 3.2) and depression (about 2.8) | That insomnia caused the later problems, because the studies were observational |
| Scullin et al., 2018 | In 57 healthy young adults, a five-minute to-do list was followed by faster sleep onset than a completed list | Whether it works for people with insomnia or an anxiety disorder, who were not tested |
| Belleville et al., 2011 | Across 72 trials of CBT for insomnia that reported anxiety, a small to moderate effect on anxiety (0.41) | Whether CBT for insomnia alone is enough when anxiety is the main problem |
Why does bedtime worry make it harder to fall asleep?
Bedtime worry, including worry about unfinished future tasks, is a significant contributor to difficulty falling asleep, according to the researchers who study it. [scullin-2018] Earlier research showed that writing about worries can help people fall asleep, which is the idea behind the bedtime to-do list below. [scullin-2018]
That points to a practical move: give the worry somewhere to go before the light goes off, instead of trying to argue it out of your head once you are lying down.
What can you do about sleep anxiety tonight?
Write a specific to-do list for the next few days for five minutes before bed, and keep the list out of the bed. In a sleep-lab study, people who did this fell asleep significantly faster than people who wrote about tasks they had already completed. [scullin-2018]
The study’s 57 participants were healthy young adults aged 18 to 30. They wrote for five minutes before an overnight sleep recording, and the more specifically they wrote their to-do list, the faster they fell asleep. People who wrote about completed activities showed the opposite trend. [scullin-2018] The limit is who was tested: healthy young adults, so the study cannot show how well the same step works for people with long-standing insomnia or an anxiety disorder. Treat it as a low-cost experiment and not a treatment.
A five-minute bedtime to-do list
Set the timer, then write what you need to remember to do over the next few days, as specifically as you can. Not 'sort out work' but 'email the invoice by noon on Tuesday'. This is our adaptation of the method in the study, so do it shortly before you turn the light off.
5:00
Stop when the timer ends, even if the list is unfinished. Leave the list outside the bedroom, and do not edit it once you are in bed.
Done. Put the list down and leave it until morning.
Three other steps are ours and were not tested in that study, but each has its own guide:
- Move the worrying earlier. Our guide to how to deal with anxiety covers setting a fixed worry time in the evening.
- Skip the clock if you wake in the night. Our guide to waking at 3am covers why checking the time backfires.
- Slow your breathing. Our guide to breathing exercises for anxiety covers the options, and grounding techniques covers what to do if you wake with your mind racing.
Does treating insomnia reduce anxiety?
A little to a moderate amount. In a meta-analysis of cognitive behavioural therapy for insomnia (CBT-I), 72 of 216 trials reported anxiety, and the combined effect on anxiety was 0.41, which the authors describe as small to moderate. [belleville-2011]
The effect did not vary with whether people also had an anxiety disorder, and adding anxiety-management strategies to CBT-I did not increase it. The authors advise checking for leftover anxiety after treatment. [belleville-2011] A separate meta-analysis of internet-delivered CBT for insomnia found a similar small improvement in anxiety, with an effect size of about 0.35 across ten studies, and called for larger, higher-quality trials. [ye-2015]
Our guide to CBT for insomnia covers what the treatment involves and the guidelines that recommend it first. If anxiety is the main problem, our guide to therapy for anxiety covers what to ask for.
Is worry about sleep running your nights?
Tick anything that has been true most nights over the last few weeks. This is a prompt for reflection, not a test, and it produces no diagnosis.
0 of 5 ticked
Several of these are in place together, which is a good reason to talk to a doctor about your sleep and your anxiety. Our CBT for insomnia guide explains the first-line treatment, and a screener result gives you something concrete to bring.
A couple of these are in place. Try the bedtime to-do list for a week and notice whether the worry loses some of its grip.
Few of these describe your nights right now. Keep the steps in mind for a stressful week.
The insomnia screener covers the sleep side. Neither screener is a diagnosis.
When to seek help
Speak to a doctor if worry about sleep has lasted several weeks, if you are regularly short of sleep during the day, or if anxiety is spreading into the rest of your life. Go sooner if you wake in a panic or if low mood has joined the picture. Do not start or stop sleep or anxiety medication without talking to a doctor.
If you feel unable to keep yourself safe, contact your local emergency services or a crisis helpline.
How MyFreud can help
Whether anxiety is costing you sleep or short nights are feeding your anxiety is hard to judge from memory at 3am. Daily mood tracking in MyFreud shows how your anxious days line up with your short nights across weeks, and the notepad gives the bedtime to-do list somewhere to live. It does not replace a doctor or CBT for insomnia.
Download MyFreud and start today: App Store or Google Play.