A patient once described her nightly routine to me this way: she’d get into bed exhausted, finally able to stop moving after a full day, and that stillness was exactly when her mind decided to start working. The email she forgot to send. The comment a coworker made that she was suddenly replaying for the tenth time. Whether her kids were doing okay. By 1 a.m. she’d often still be awake, now anxious about being awake, which made falling asleep even less likely. This is one of the most common cycles I see in my Long Island practice, and it’s rarely just a sleep problem or just an anxiety problem. It’s both, feeding each other in a loop that’s genuinely difficult to break without outside help.
The Cycle, Explained
Anxiety disrupts sleep by keeping the nervous system activated exactly when it needs to be winding down. Poor sleep, in turn, worsens anxiety, because a sleep-deprived brain has a measurably harder time regulating emotional responses and distinguishing real threats from perceived ones. Each night of poor sleep makes the next day’s anxiety more likely, which makes the following night’s sleep harder, and the pattern compounds over weeks or months until a person can no longer identify which problem came first.
Why Bedtime Is When Anxiety Gets Loudest
During the day, most people have enough external stimulation, work, conversations, tasks, to keep anxious thoughts from fully taking over. At night, once the distractions disappear, there’s often nothing left to compete with them. This is why so many patients describe feeling fine all day and then hitting a wall of worry the moment their head touches the pillow. Anxiety doesn’t wait for nighttime to appear; nighttime is simply when nothing is left to drown it out.
The Role of Rumination
What often keeps a person awake isn’t a single worry but a specific mental habit: rumination, the tendency to replay the same handful of thoughts on a loop without resolving any of them. Rumination feels productive in the moment, as though enough repetition will eventually produce an answer or a sense of control, but it rarely does. Instead it keeps the nervous system activated well past the point where the original concern had anything useful left to offer. Research on rumination has found that it consistently prolongs and intensifies negative mood rather than resolving it, which is part of why it interferes so directly with the ability to fall asleep. Patients frequently describe knowing, even in the moment, that going over the same conversation for the twentieth time isn’t helping, and being unable to stop anyway. This is a learned mental pattern, not a character flaw, and it responds well to specific treatment rather than willpower.
Common Patterns We See
Difficulty falling asleep. Racing thoughts that start the moment the lights go off, often centered on the day that just happened or the day about to come.
The 3 a.m. wake-up. Waking in the middle of the night with a suddenly alert, anxious mind, often replaying something minor into something that feels much larger at that hour than it will in daylight.
Anticipatory dread about sleep itself. For patients with a long enough history of this pattern, anxiety about not being able to sleep becomes its own separate problem, sometimes worse than whatever originally kept them up.
Non-restorative sleep. Technically sleeping seven or eight hours but waking up exhausted, because the sleep itself was shallow and interrupted by an activated nervous system.
A telling clue: vacation sleep. Many patients notice they sleep significantly better on vacation or over a relaxed weekend, even in an unfamiliar bed. That pattern is a useful sign that the disruption is anxiety-driven rather than a primary sleep disorder, since a physiological sleep problem typically wouldn’t resolve itself just because the calendar cleared.
How This Differs From a Primary Sleep Disorder
Not all insomnia is anxiety-driven, and it’s worth knowing the difference before assuming this pattern applies to you. Conditions like sleep apnea, restless leg syndrome, or a disrupted circadian rhythm from shift work or irregular schedules can all produce similar-looking sleep complaints and deserve their own medical evaluation. What tends to distinguish anxiety-driven insomnia is the content of the wakefulness itself: a mind that’s actively working, worrying, or replaying, rather than simply unable to physically settle. Patients with a primary sleep disorder often describe frustration at being awake with nothing in particular on their mind, while patients with anxiety-driven insomnia almost always have something they can point to, even if it takes a moment to name it. When both are present, and they sometimes are, treating the anxiety alone won’t fully resolve a physiological sleep disorder, which is one more reason an honest look at what’s actually happening matters more than reaching for a single explanation.
A Note on Alcohol and Sleep Aids
It’s common for patients managing anxiety-driven insomnia to reach for a glass of wine to unwind or an over-the-counter sleep aid to force the issue. Both can create the appearance of solving the problem while making the underlying pattern worse over time: research on alcohol’s effects on sleep has found it disrupts the second half of the sleep cycle even as it helps someone fall asleep faster, suppressing REM sleep and increasing fragmentation later in the night. Reliance on sleep aids carries a similar trade-off, since it can prevent the nervous system from ever learning to regulate itself without them. Neither is a moral failing, and plenty of reasonable people land here after months of exhaustion, but it’s worth naming as part of the pattern rather than treating as a separate habit unrelated to the anxiety driving it.
The same is often true of caffeine, especially for patients already running an anxious nervous system. A systematic review of the research found that caffeine reliably prolongs sleep latency and reduces total sleep time, effects that compound directly with anxiety-driven insomnia rather than existing separately from it.
What Doesn’t Usually Work Long-Term
Most people try the standard advice first: no screens before bed, chamomile tea, a consistent bedtime. These aren’t bad ideas, and some genuinely help at the margins. But for anxiety-driven insomnia, sleep hygiene alone rarely resolves the core problem, because it doesn’t address why the nervous system won’t power down in the first place. Treating the symptom without treating the anxiety underneath it tends to produce limited, short-lived improvement. For some patients, better sleep hygiene really is enough, and that’s a legitimate place to stop; for others, the pattern runs deeper and needs to be addressed directly.
How We Treat This
We use Cognitive Behavioral Therapy for Insomnia principles alongside anxiety-specific CBT to address both the sleep pattern and the anxious thoughts driving it simultaneously, including specific techniques for interrupting rumination once it starts rather than trying to prevent it from occurring at all. A meta-analysis of randomized controlled trials found that CBT for insomnia produces measurable improvement in comorbid anxiety, not just sleep quality, which fits what we see clinically: treating the sleep pattern directly tends to ease the anxiety riding along with it. Stimulus control and sleep restriction techniques, borrowed from insomnia treatment specifically, help retrain the association between bed and sleep rather than bed and worry. ACT techniques help patients build a different relationship to nighttime anxious thoughts, learning to notice them without immediately engaging or trying to solve them at 1 a.m. For patients whose anxiety has deeper roots, whether in trauma, family history, or long-standing patterns, Dynamic Experiential Learning and Psychodynamic Therapy address what the anxiety is actually about, which often has little to do with the specific thought keeping them up on any given night. As with the physical symptoms of anxiety more broadly, not everyone needs or wants this deeper layer; a shorter course focused specifically on the sleep-anxiety cycle is often enough.
A 2024 study published in Sleep Medicine followed a large cohort over time and found that sleep disturbance and anxiety are mutually reinforcing, with poor sleep actually the stronger predictor of later anxiety in that data, underscoring why treating sleep and anxiety as separate problems so often fails to resolve either one.
A Composite Case
A Merrick mother of two came to see me describing almost a year of broken sleep, always at the same time, always around 2 or 3 a.m. She’d tried melatonin, a sleep tracker, and cutting out caffeine entirely, with no real change. In session, it became clear that her wake-ups weren’t random. They tracked almost exactly with an ongoing conflict with her sister that she wasn’t fully processing during the day, the kind of unresolved relational anxiety that often surfaces once the day’s distractions fall away. Once we began addressing the underlying anxiety directly in session, rather than only troubleshooting her sleep routine, the nighttime wake-ups became less frequent within a few weeks, without a single change to her sleep hygiene.
When to Seek Help
If poor sleep and anxiety have been feeding each other for more than a few weeks, and self-directed strategies haven’t made a real difference, it’s worth treating this as what it actually is: an anxiety pattern with a sleep symptom, not the other way around.
Frequently Asked Questions
Should I try medication for sleep first?
That’s a conversation to have with a prescribing physician. Many patients benefit from addressing the underlying anxiety in therapy either alongside or instead of medication, depending on the situation.
Is this the same as insomnia?
Insomnia is the sleep symptom. What we’re describing here is often insomnia with an anxiety disorder underneath it, which changes what actually needs to be treated.
Can therapy really help me sleep better?
Yes, particularly when the sleep disruption is anxiety-driven rather than caused by an unrelated medical or environmental factor.
Getting Help in Nassau County: If your nights have started to feel like a repeating cycle you can’t think your way out of, Contact Us → to talk about what’s actually keeping you up.
References: Peng, A., Ji, S., Lai, W., Hu, D., Wang, M., Zhao, X., & Chen, L. (2024). The bidirectional relationship between sleep disturbance and anxiety: Sleep disturbance is a stronger predictor of anxiety. Sleep Medicine, 121, 63-68.
Nolen-Hoeksema, S., Wisco, B.E., & Lyubomirsky, S. (2008). Rethinking rumination. Perspectives on Psychological Science, 3(5), 400-424.
Ye, Y.Y., Zhang, Y.F., Chen, J., Liu, J., Li, X.J., Liu, Y.Z., Lang, Y., Lin, L., Yang, X.J., & Jiang, X.J. (2015). Internet-based cognitive behavioral therapy for insomnia (ICBT-i) improves comorbid anxiety and depression: A meta-analysis of randomized controlled trials. PLOS ONE, 10(11), e0142258.
Chaput, J.P. (2026). Alcohol, Wine, and Sleep in Adults: Insights from a Narrative Review. Nutrients, 18(4), 585.
Clark, I., & Landolt, H.P. (2017). Coffee, caffeine, and sleep: A systematic review of epidemiological studies and randomized controlled trials. Sleep Medicine Reviews, 31, 70-78.
Dr. Marc J. Shulman, Psy.D., Founder & Director, Long Island Psychology
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