How to break the cycle of anxiety and poor sleep

It is well recognised that anxiety is frequently connected to sleep problems. The mental health charity Mind, for example, emphasises that poor sleep can affect your mental health but poor mental health can also affect how you sleep.

It stands to reason that if your mind is racing at night – whether it's about money or job worries, concerns about the family or health or just some other stressor in your life – this will probably make it harder to get to sleep and may keep you tossing and turning if you do wake up.

'Sleep evangelist' and scientist Dr Sophie Bostock highlights how such periodic waking is a normal part of our sleep cycles. Normally this is not a problem – we'll just roll over and go back to sleep – but if we're anxious or fretting about something it can cause insomnia, wakefulness and disturbed sleep.

Dr Bostock looks at how poor sleep and anxiety are linked. Importantly, she also gives helpful tips and strategies you can use to address this, especially approaches based around cognitive behavioural therapy and mindfulness.

Why does stress and worry make us more vulnerable to poor sleep? To answer this, Dr Bostock highlights that it all comes down to how our brain responds to 'threat'.

"If our brains sense danger, if we feel anxious or threatened, or if we're in a situation which is out of our control, we ramp up our 'fight or flight' stress response," she warns.

"This is designed to keep us on high alert and ready to run. The body releases adrenalin, speeds up the heartbeat, increases blood-flow to the muscles, and releases glucose into the bloodstream to fuel the body ready for action. We also release the stress hormone cortisol.

"This is why, when we feel anxious, we may notice a pounding heartbeat, feel flushed or sweaty or tense. If you experience high levels of stress or worry before bed, it can interfere with the release of melatonin, the hormone that signals the body to get ready for sleep. With less melatonin, it takes us longer to fall asleep and our sleep can become lighter.

"This means we are more likely to be woken by noise, movement or changes in temperature. Anxiety can also lead to changes in our daily habits that are unhelpful for sleep, such as having less time and energy for exercise, relying on alcohol to relax, or working late if we're worried about work pressures. These can all interfere with the quality of our sleep," Dr Bostock adds.

All this therefore helps to explain how anxiety can worsen sleep. But is there any evidence that lack of sleep can also add to anxiety? In short, yes there is, argues Dr Bostock.

"Brain imaging studies show that lack of sleep makes us more reactive to negative events. The amygdala, the part of the brain which switches on our 'fight or flight' stress response, becomes more sensitive after a restless night," she points out.

"It's as if the brain interprets a lack of sleep as a signal that we could be in danger; we're more likely to feel tense, defensive and anxious. So, by cruel irony, one of the consequences of poor sleep is that we become more worried about not being able to sleep. Our beliefs about sleep can become unhelpfully distorted. We can start to worry that we will never sleep well again.

"Sleep disruption also interferes with our concentration, patience and ability to empathise, which can make us both struggle with productivity and relationships, leading to further life stress and giving us more things to worry about. Fortunately, because the relationship between sleep and mental health goes both ways, we now know that anything you do to improve your sleep will have knock-on benefits for your mental health," Dr Bostock adds.

What, therefore, can we do to break this vicious cycle? What strategies or approaches can we use to get our sleep back on track?

Dr Bostock first makes the important point that, if you're suffering from severe anxiety or sleep problems to the extent that this is interfering with your day-to-day life, speak to your doctor. "They might want to rule out medical causes for symptoms before discussing treatment options. The recommended first-blind treatment for both anxiety and insomnia is cognitive behavioural therapy, or CBT, a talking therapy approach that addresses unhelpful thoughts and behaviours that make both conditions persist," she advises.

CBT is an important and successful tool for managing both anxiety and sleep disorders, she points out. "CBT teaches you to recognise that thoughts are just thoughts, and we have a choice about which ones we respond to. Unhelpful thoughts are often accompanied by unhelpful emotions. If we challenge the thoughts, we can change our emotional and behavioural responses."

CBT for insomnia emphasises the value of good 'sleep hygiene' behaviours, Dr Bostock points out, such as waking up at the same time every day, regardless of how well you slept the night before.

"Get your body moving every day to help increase your drive for sleep. Only get into bed when you're sleepy and get out of bed when you're not. And limit caffeine. This is because caffeine can actually heighten the stress response and make you feel jittery. Switch caffeine for decaf in the afternoons," she emphasises.

CBT for anxiety, conversely, focuses more on encouraging you to develop a 'wilful tolerance' through deliberately choosing to expose yourself to whatever it is that is making you anxious.

"For example, if you have social anxiety, it might be opting to go to a social event that you might normally avoid," explains Dr Bostock. "It is about learning to anticipate, recognise and tolerate the discomfort of anxiety until the brain realises that there is less to fear than it thought. But it is really important this is done in a planned and supported way, to avoid being overwhelmed."

'Mindfulness' is another approach commonly used within CBT for both insomnia and anxiety, Dr Bostock highlights.

"Mindfulness refers to the ability to be fully present in the moment; aware of what you're doing and feeling but not overly reactive. Being mindful about your emotions is like being able to pull up a deckchair in your mind, sit back and watch thoughts and feeling pass by like clouds without getting caught up in them," she explains.

"This can be a useful approach if you are kept awake by a racing mind. Mindfulness is a quality that we all have but can be cultivated with practise. Research shows that mindfulness-based training can be effective for reducing insomnia symptoms as well as helping people to manage stress, anxiety, depression and chronic pain," she adds.

How, then, in practice can you go about becoming more mindful? What techniques might you be able to adopt and incorporate into your day-to-day life?

"Traditionally, mindfulness meditation involves sitting quietly, focusing your attention on parts of your body or your breath as you allow thoughts and feelings to come and go. Each time you realise that you have become distracted, you gently return your attention back to your body," recommends Dr Bostock.

"You can also practise being more mindful when you're walking around. Or brushing your teeth. Whatever you're doing, you focus your attention on that activity and, as you notice that you become distracted, you gently bring your awareness back. The key to mindfulness is regular practise," she adds.

Another key is to recognise it can be harder to be mindful when you’re short of sleep. "So, you might want to start off with just five minutes of deliberate practise a day and gradually build that up as you get used to it. There are lots of apps, such as Headspace and Calm, which teach mindfulness. Alternatively, you could sign up for a group course or one-to-one training," Dr Bostock advises.

Finally, Dr Bostock recommends a technique called 'progressive muscle relaxation'. “This is something you can use at any time of day or night to help relieve anxiety and get ready for sleep. It involves tensing and then relaxing all the major muscle groups. I'd recommend starting with your toes and working your way up," she explains.

As an example, she highlights how you can shrug your shoulders hard, bringing them right up towards your ears and squeezing firmly for a slow count of five. "Then gently release. And enjoy the sensation of tension leaving the body. Each time you breathe out imagine the tension flowing out from your neck, out from your shoulders, out from your arms, out from your hands, and drifting away. Just let your shoulders relax," she says.

"We often carry a lot of tension in our muscles without even realising it. When we relax our muscles, we also relax our minds. Regularly practising progressive muscle relaxation has been shown to help stress, anxiety, high blood pressure, back pain, migraines and poor sleep," Dr Bostock adds.

In summary, she concludes, focusing on these three approaches can often make a real difference. As Dr Bostock puts it: "Sleep hygiene, wilful tolerance, mindfulness and progressive muscle relaxation are all CBT strategies which could help to reduce anxiety and improve your sleep."

Nic Paton is one of the country's foremost journalists on workplace health, safety and wellbeing, and is editor of Occupational Health & Wellbeing magazine. He also regularly writes on the health and employee benefits and health insurance markets.