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Sleep and anxiety: From mechanisms to interventions
Abstract
Anxiety is the most common mental health problem worldwide. Epidemiological studies show that sleep disturbances, particularly insomnia, affect ∼50% of individuals with anxiety, and that insufficient sleep can instigate or further exacerbate it. This review outlines brain mechanisms underlying sleep and anxiety, by addressing recent human functional/structural imaging studies on brain networks underlying the anxiogenic impact of sleep loss, and the beneficial effect of sleep on these brain networks. We discuss recent developments from human molecular imaging studies that highlight the role of specific brain neurotransmitter mechanisms, such as the adenosinergic receptor system, on anxiety, arousal, and sleep. This review further discusses frontline sleep interventions aimed at enhancing sleep in individuals experiencing anxiety, such as nonbenzodiazepines/antidepressants, lifestyle and sleep interventions and cognitive behavioral therapy for insomnia. Notwithstanding therapeutic success, up to ∼30% of individuals with anxiety can be nonresponsive to frontline treatments. Thus, we address novel non-invasive brain stimulation techniques that can enhance electroencephalographic slow waves, and might help alleviate sleep and anxiety symptoms. Collectively, these findings contribute to an emerging biological framework that elucidates the interrelationship between sleep and anxiety, and highlight the prospect of slow wave sleep as a potential therapeutic target for reducing anxiety.
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“Cognitive models of insomnia and emerging data linking circadian factors to affective dysregulation suggest how pre-sleep anxiety amplifies threat monitoring and hyperarousal, thereby delaying sleep initiation [3,4].”
From Pre-Sleep Anxiety: Mechanisms and Therapeutic Approaches in Clinical Practice. (2026) · cites this paper as [3]
In the citing paper
“The condition is often accompanied by mental distress and physical tension, further compounding sleep difficulty [3].”
From Pre-Sleep Anxiety: Mechanisms and Therapeutic Approaches in Clinical Practice. (2026) · cites this paper as [3]
In the citing paper
“Sleep onset anxiety, a heightened state of worry and cognitive arousal occurring during the transition to sleep, functions as a transdiagnostic symptom cluster that increases vulnerability to insomnia rather than constituting a standalone disorder [3].”
From Pre-Sleep Anxiety: Mechanisms and Therapeutic Approaches in Clinical Practice. (2026) · cites this paper as [3]
In the citing paper
“Sleep onset anxiety commonly occurs with generalized anxiety disorder (GAD), panic disorder (PD), and post-traumatic stress disorder (PTSD) [3].”
From Pre-Sleep Anxiety: Mechanisms and Therapeutic Approaches in Clinical Practice. (2026) · cites this paper as [3]
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“Sleep disturbance is a common feature of both anxiety and depressive disorders (Chellappa & Aeschbach, 2022; Pandi-Perumal et al., 2020).”
Liu, B., Shi, P., Jin, T., & Feng, X. (2025) · Archives of Public Health · doi:10.1186/s13690-024-01493-0 · Cited by 5
“Secondly, in terms of mental health, sleep deprivation can increase the risk of depression and anxiety [74, 75], which can interfere with attention and learning efficiency.”
Wang, X., Kong, X., Ding, Y., An, M., Zhu, X., Guan, Y., & Niu, Y. (2025) · Journal of Neuroinflammation · doi:10.1186/s12974-025-03447-x · Cited by 5
“Sleep deprivation has been shown to induce anxiety in both humans and rodents [69, 70], possibly mediated by neurotransmitter and neuro-modulatory systems [71].”
Guo, Y., Miao, X., Chen, Y., Ding, L., Zhao, K., Xu, T., Chen, L., Xu, X., & Xu, Q. (2025) · Annals of Surgical Oncology · doi:10.1245/s10434-025-18026-w · Cited by 5
“36,37 Therefore, after anxiety is alleviated, patients are more likely to resume a normal diet, improve sleep quality, and enhance physical activity, thereby effectively slowing the evolution of the frailty trajectory.”
Bastos, L. M. V., Viana, L. M. C., Peixoto, M. C. B. G., Pimentel, I. D. S., de Figueirêdo, L. R. B., Jereissati, L. D. O., Lima, L. M. F. V., Aguiar, A. B., & dos Santos, J. C. C. (2023) · Brazilian Journal of Health Review · doi:10.34119/bjhrv6n4-185 · Cited by 6
“Epidemiological studies reveal that about 50% of individuals with anxiety have sleep disorders, especially insomnia, and that insufficient sleep can further stimulate or exacerbate this condition (24).”
BackgroundInfluentialAnxious-Withdrawal and Sleep Problems during Adolescence: The Moderating Role of Peer Difficulties
Bowker, J. C., Gurbacki, J. N., Richard, C. L., & Rubin, K. H. (2023) · Behavioral Sciences · doi:10.3390/bs13090740 · Cited by 4
“In such research, measures of anxiety and negative cognitions should also be included to evaluate the proposed mechanisms of influence in this study [50,51].”
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“Some studies also proved that depression (40) and anxiety (41) symptoms could be ameliorated by improving sleep problems.”
BackgroundKravitz, H. M., Ruppert, K. M., Lian, P., Neal-Perry, G. S., & Swanson, L. M. (2024) · International Journal of Women s Health · doi:10.2147/ijwh.s455834 · Cited by 7
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“Given that negative emotions can be instigated and further exacerbated by sleep disturbances [45], the increased sleep quality provided by weighted blanket intervention might be an explanation for the beneficial effects on anxiety and stress.”
BackgroundLa ansiedad y su relación con el síndrome burnout en docentes universitarios
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“Anxiety disorders are the most common mental illness [41-44]; they affect about one in ive people globally and are among the most frequently diagnosed psychiatric disorders in youth [45,46].”
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“Some of them have focused their attention on investigating the bidirectional correlation between sleep habits and emotional regulation [46,47], whereas others have observed the influence of emotional regulation on health habits such as sleep [48,49].”
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“V e n e r e o l o g i ca Z. Wu et al. “Causal relationships between atopic dermatitis and psychiatric comorbidities” 6/7 Acta Derm Venereol 2025 bances, particularly insomnia, affect approximately 50% of individuals with anxiety and can exacerbate the condition (32).”
Zhong, L., Ma, X., Li, S., & Ling, Y. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1563237 · Cited by 5
“Prior research suggests that trait anxiety may impair sleep quality via heightened stress responses and disrupted neuroregulatory mechanisms, such as HPA axis dysregulation and neurotransmitter imbalance (e.g., glutamate and GABA) (19, 20).”
Hu, P., Li, K., Han, Y., Wang, X., & Xiao, Z. (2025) · BMC Neurology · doi:10.1186/s12883-025-04313-2 · Cited by 4
“…shown that individuals with high levels of neuroticism are more sensitive to stressful life events, tend to amplify stress and hyperfocus in the external environment, and have poor emotion regulation, leading to significant anxiety and depression, and an increased risk of insomnia [49, 55, 56].”
The impact of physical activity on sleep architecture and cognitive function among college students
Ji, Y., Wang, B., Sun, X., Wang, Z., & Chen, W. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1656278 · Cited by 4
“This slow-wave sleep promotes bodily and neural recovery, facilitates the clearance of metabolic waste, and supports memory consolidation (14).”
Wu, Q., Zhou, X., & Xu, L. (2025) · Sleep Medicine · doi:10.1016/j.sleep.2025.106883 · Cited by 4
A latent class analysis of co-occurring insomnia and anxiety among Chinese pregnant women
Liu, S., Huang, M., Tao, J., Wen, D., Ping, Z., Zhang, F. Y., & Li, M. (2024) · Journal of Psychosomatic Obstetrics & Gynecology · doi:10.1080/0167482x.2024.2437391 · Cited by 4
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“There are various subtypes of anxiety disorders, including general anxiety disorder, panic disorder, social anxiety disorder, and agoraphobia [2].”
Dhamelia, P., Gupta, V., Agarwal, S., Singh, B., & Jain, R. (2025) · The Open Respiratory Medicine Journal · doi:10.2174/0118743064411633250826105304 · Cited by 5
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“Insomnia impacts the patient’s quality of life and exhibits a causal relationship with physical and mental illnesses, including cardiovascular disease (6), anxiety (7), depression (8), and even cancer (9).”
BackgroundLederer-Hutsteiner, T., Müller, K. W., Penker, M., Stolz, E., Greimel, E., & Freidl, W. (2024) · Frontiers in Public Health · doi:10.3389/fpubh.2024.1422157 · Cited by 7
“For example anxiety problems may both prolong but also result from sleep problems and therefore act in a bidirectional relationship as a cause, but also as a consequence of insufficient sleep (29, 30).”
BackgroundGordon, C. M., Dugan, V., Hörmann, C., & Montoya, P. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13237226 · Cited by 4
“Anxiety and sleep have a bidirectional relationship, i.e., as one increases or decreases so may the other [58].”
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“Previous research established the interrelationship between sleep, anxiety, and depression (95–98).”
Circadian and Sleep Modulation of Dreaming in Women with Major Depression
Birchler-Pedross, A., Frey, S., Cajochen, C., & Chellappa, S. L. (2022) · Clocks & Sleep · doi:10.3390/clockssleep4010012 · Cited by 4
“Likewise, anxiety is frequently comorbid to disrupted sleep and to MDD [42] and often affects dream recall and its emotional salience [37,43].”
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Milanak, M. E., Witcraft, S. M., Park, J. Y., Hassell, K., McMahon, T. P., & Wilkerson, A. K. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1160001 · Cited by 4
“This session follows the structure and content of a typical CBT-I introductory session.”
BackgroundInfluentialLiu, Y., Ge, X., Zhang, J., Xu, L., Hu, F., Wang, S., Liu, J., Yang, X., Shi, D., & Cai, Y. (2023) · BMC Public Health · doi:10.1186/s12889-023-15803-8 · Cited by 5
“Sleep disturbance could increase the risk of anxiety through a shared and mutually reinforcing neurocircuitry involving dopamine, serotonin, and adenosine [41].”
Background
Metadata
- Authors
- Chellappa, S. L., & Aeschbach, D.
- Affiliations
- University of Cologne (DE)
- University of Bonn (DE)
- Corresponding author
- Chellappa, Sarah L.
- Venue
- Sleep Medicine Reviews
- Publisher
- Elsevier BV
- Published
- 2022-02
- Volume
- 61
- Pages
- 101583
- ISSN
- 1087-0792 (ISSN-L)
- OpenAlex
- W4200462974
- Cited by
- 509
- References
- 158
- Citations by year
- 2026: 111 · 2025: 170 · 2024: 135 · 2023: 71 · 2022: 21
- FWCI
- 9.43
- Type
- journal article
- Language
- en
- Open access
- closed
- Licence
- Locations
- Sleep Medicine Reviews (publishedVersion)
- PubMed (publishedVersion)
- Kölner Universitäts PublikationsServer (Universität zu Köln) (publishedVersion)
- elib (German Aerospace Center) (acceptedVersion)
- ePrints Soton (University of Southampton) (submittedVersion)
- Funders
- Alexander von Humboldt Foundation
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Life Sciences › Neuroscience › Cognitive Neuroscience › Sleep and Wakefulness Research
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- sleep, anxiety, insomnia, sleep deprivation, brain networks, arousal, cognitive behavioral therapy for insomnia, non-benzodiazepine hypnotics, antidepressants, lifestyle intervention, non-invasive brain stimulation, slow-wave sleep, sleep interventions
- MeSH terms
- Anxiety, Anxiety Disorders, Humans, Sleep Initiation and Maintenance Disorders, Sleep, Cognitive Behavioral Therapy
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