“Sleeping through the night” or colloquially “eating the roof” describes the unpleasant experience of remaining in bed unable to sleep, caught up in a constant rush of thoughts, watching the hours tick by on the clock. One of these common circular thoughts is “I need to sleep.” Unfortunately, the anxiety resulting from lack of sleep is in itself a cause of insomnia.
Anticipatory worry about the possibility of not sleeping well can become a sad paradox: the fear of insomnia ends up causing precisely what we want to avoid. This vicious cycle is well known among sleep specialists and is the subject of numerous studies. The end result is insomnia, a problem that can seriously affect mental and physical health. Fortunately, there are treatments to get out of this trap.
The most common causes of insomnia
The causes of insomnia are diverse and range from organic causes to emotional changes. In medicine, a distinction is made between primary insomnia, which arises for no apparent reason, and secondary insomnia, which is linked to medical and psychological causes and is often due to stressful situations or life changes. The most common causes include anxiety disorders, depression, stimulant use, schedule changes, medical problems or chronic pain.
Unfortunately, the anxiety resulting from lack of sleep is itself a cause of insomnia.
In anxiety disorders, there is also physical activation (palpitations, muscle tension, repetitive thoughts) that changes the structure of sleep, that is, makes it difficult for us to enter the deep stages of sleep during the night. In people who suffer from panic attacks, sudden awakenings in the deep stages of sleep are common, generating long periods of nocturnal wakefulness.
“What happens is that those who are afraid of not sleeping, and this generates anxiety, we call them insomniacs, and those who do not sleep because they have anxiety we call them anxious. But they are two sides of the same coin,” explains Dr. Francesca Canellas, a psychiatrist specializing in sleep medicine and researcher at the Institute of Health Research of the Balearic Islands.
It is easy to understand that there is a vicious cycle between anxiety and insomnia. Sleep deprivation increases the brain’s response to stress, while chronic anxiety makes it difficult to fall asleep and stay asleep. Brain studies have shown that lack of rest leads to an exaggeration in the response of emotional centers in the brain, such as the amygdala, to anxiety-provoking situations, which researchers call anticipatory anxiety.
Those who are afraid of not sleeping, and this generates anxiety, we call insomniacs, and those who do not sleep because of anxiety we call anxious. But they are two sides of the same coin
Francesca Canellas
— Sleep psychiatrist
The pandemic has been a laboratory for many aspects of mental health, and a study during that period found that those who sleep less or go to bed late have greater anxiety and depression. These findings are consistent with the theory that lack of REM sleep, during which dreams occur and emotions are processed, produces mood disorders.
Worrying about not being able to sleep
The so-called sleep anxiety is, as we have seen, the anticipated anxiety about not being able to sleep, which often manifests itself in people who have suffered from previous bouts of insomnia or in people who have experienced trauma. It’s a vicious cycle: while we feel anxious about the fear of lack of rest, the nervous system activates and pulls us out of the relaxed state necessary for sleep.
“It is one of the factors that perpetuate the problem of insomnia, because insomnia ultimately generates a state of anxiety,” comments Dr. Celia García Mallo, neurologist at the Cisne Clinic, sleep specialist and coordinator of the Sleep Study Group of the Spanish Society of Neurology. “When night comes, the patient is very active, and even feels it as a threat, as an unpleasant moment, and becomes more alert, which means he will sleep worse or take longer to fall asleep,” he adds.
Recent research highlights that sleep deprivation, even for just one night, can significantly increase the tendency toward anxiety and anticipatory anxiety. In more severe cases, something called insomnia identity develops, which is the belief that you have insomnia, which in itself can cause it.
How to treat anxiety caused by insomnia
Treatment of insomnia and related anxiety has two aspects: pharmacological and non-pharmacological. The choice depends on the severity, timing and context of each person.
Sleeping pills and anxiolytics can be helpful for brief interventions, but they should not be the first or only response and, above all, should never be used without medical supervision. But this is not the case in Spain, where one in ten people use them regularly, with or without a prescription, according to a report by the Ministry of Health.
“Anxiolytics work because what they do is reduce anxiety,” Dr. Canelas explains. “What happens is that they create dependence and tolerance, and if you stop taking them, a withdrawal syndrome occurs, and that is the serious problem. They can only be taken for a very limited time because, if not, their effect stops. And then not only does it have no effect, but it is dangerous. In cases of anxious patients, in the long term, we use selective serotonin reuptake inhibitors (antidepressants), which do not work immediately but work in the long term, and which somehow act on the anxiety-producing pathways,” he adds.
Cognitive behavioral therapy for insomnia (CBT-I) is the most commonly used “pill-free” intervention. There is research showing long-term improvements, and unlike medications, it has no major side effects. This therapy addresses each person’s sleep-related thoughts, beliefs, and behaviors. For example, it changes the way a person focuses on their worries before bed, often using relaxation techniques and positive reinforcement routines.
“This means reframing sleep as another part of normal life. Just as people are hungry and eat, they are sleepy and sleep, right?” Dr. Garcia explains. “Sometimes attention control techniques are used, such as meditation or counting backwards a series of numbers, and observing the stimuli and associations that are generated. Sometimes time in bed is also restricted, i.e. preventing them from staying up for too long in bed, because generally all they do is think and they become more tired.”
Sometimes, the time they spend in bed is also restricted, i.e. preventing them from staying up for a long time in bed, because generally all they do is think and become more tired.
Celia Garcia Malo
— A neurologist specializing in sleep
This approach not only treats insomnia but also the anxiety associated with it. Another common intervention with CBT-I is regular physical exercise, especially moderate-intensity exercise (such as walking, yoga, Pilates), which helps reduce stress, improve the quality and quantity of sleep, regulate circadian rhythms and promote deep sleep.
mindfulness meditation (Mindfulness) is another tool that has shown benefits in reducing anticipatory anxiety and rumination, i.e. circular thoughts, which are often accompanied by hypervigilance and sleep sabotage. Conscious breathing and progressive relaxation exercises work not only at bedtime, but also during the day, helping to reduce brain activation.
As always, sleep hygiene, the set of habits that facilitate restful sleep, is the foundation to start when there are difficulties sleeping: maintaining regular schedules, avoiding screens and bright lights, reducing caffeine and alcohol consumption, keeping the bedroom cool, dark, and quiet, and using the bed only for sleep or sexual activity. These guidelines, although simple, can make a big difference.
Dario Pescador is editor and magazine director Co Magazine And the author of the book Better yourself.