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Sleep and anxiety: a vicious cycle

Have you ever had trouble falling asleep the night before a big presentation at work or an important social event? You want to do your best and know you must be alert and well rested to get the job done. Yet if you cannot get to sleep, you can become anxious about how you will perform and–even more frustrating–you can also become anxious about your inability to sleep. This can even happen when you anticipate positive or happy events the next day. For example, kids often don’t sleep well on Christmas eve, and are up much earlier than their parents would like–because they are anxious to see what Santa brought them (I know I was). The association between insomnia and anxiety is a two-way street. It has been well established that anxiety can be a major contributor to difficulty sleeping, especially in those who have an anxiety disorder. But difficulty sleeping can also increase your anxiety about falling/staying asleep, which can create a vicious cycle.

“When I can’t fall asleep, I get anxious; and when I’m anxious, I can’t fall asleep.”

This is a direct quote from an individual with a long history of insomnia. It underscores the double whammy effect that worrying about falling asleep can cause. In the field of Sleep Medicine, this type of insomnia is called psychophysiological insomnia. The term “psychophysiological” is a combination of the words psychological and physiological. Sometime this term is misconstrued, with people focusing too much on the psychological part of the word, and thinking that their insomnia is being trivialized or, is “all in their head”. What is often overlooked is that the worry about falling asleep can actually cause measurable physiological arousal, which is counterproductive to sleep.

This type of insomnia not only makes it difficult to fall asleep, it can also make it difficult to stay asleep. It is normal for adults to have a few awakenings during sleep, but sometimes when you wake up, that same worry can kick in and keep you awake longer than otherwise. When you are awake in the middle of the night and it’s still dark outside, things can loom disproportionately large. An otherwise minor concern about something can get blown out of proportion. A glance at a clock showing precious few hours before you need to wake can send you into an anxious spiral, making you fret that you need to try harder to fall asleep.

I have heard the phrase “try harder to get to sleep”, or some variant, many times: as if a person could clench their fists, shut their eyes tight, and will themselves to sleep. However, trying hard to get to sleep is counterproductive; things that seem to make sense in the middle of the night don’t always add up in the light of day. One way to look at it is that we can’t make sleep happen–we have to allow it to happen.

If this psychophysiological insomnia persists for a while, people can begin to develop learned sleep-preventing associations. Sometimes, they can develop a pattern of increasing anxiety as it gets close to bedtime, with the actual act of going to bed making it even worse. The bed can become a stimulus that elicits anxiety, practically guaranteeing that you won’t get to sleep.

This is why it is often recommended that you only use your bed for sleep and sexual activity. It’s important to break that negative association and replace it with a positive one.

April being tax time, I had someone with insomnia tell me that they did their taxes in bed, turned out the light, and then were frustrated when they could not get to sleep. Tip: if you have insomnia, it’s probably not a good idea to do your taxes in bed.

Another contributor to this type of insomnia can be racing thoughts, where the mind refuses to turn off. Although one might expect this to affect only those grappling with major issues, many who experience this say they just can’t stop thinking about otherwise minor things. I have heard from people who can’t stop making grocery or chore lists, for example. Those dirty dishes in the kitchen sink may call out to you when you turn the light out. Racing thoughts, emotional events, worry, frustration, and anxiety about getting to sleep all cause arousal that can prevent the very thing that you want and need: a good night’s sleep.

If you are prone to insomnia, always try to practice good sleep hygiene. But if this does not resolve your problem, be aware that help is available to break the vicious cycle, and reduce the physiological arousal caused by anxiety about sleeping.

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