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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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Chrononutrition for the Management of Obesity in Aging
Jagota, A., Priyanka, & Bussa, B. R. (2026) · Healthy ageing and longevity · doi:10.1007/978-3-032-24097-2_25
Wang, Q., Ren, J.-J., & Zhao, J. (2026) · Medicine · doi:10.1097/md.0000000000049956
“Anxiety manifests not only as emotional restlessness and worry but is often accompanied by physical discomfort, such as insomnia and muscular tension, [6,7] which may directly interfere with daily life and affect cognitive function.”
Zhu, Y., Sun, M., Li, J., Sun, Z., Lou, Z., Shi, Y., Wu, Y., Yuan, Y., Qin, S., & Shen, Y. (2026) · Frontiers in Psychology · doi:10.3389/fpsyg.2026.1778636
Lin, Z., Wang, D.-C., Nie, Y.-Y., Tan, C., & Liu, Z.-C. (2026) · Psychology, Health & Medicine · doi:10.1080/13548506.2026.2708207
Li, Y., Wan, X., Ru, A., Wang, Y., Wang, J., Liu, Y., Liang, Z., Zhang, H., & Bao, Y. (2026) · Frontiers in Psychology · doi:10.3389/fpsyg.2026.1853278
“Within this population, anxiety functions as a substantial psychological stressor that disrupts sleep architecture and degrades SQ. High anxiety levels typically predict prolonged sleep onset latency, reduced total sleep duration, and diminished sleep efficiency (Chellappa and Aeschbach, 2022).”
Impaired Alertness Correlates With Chronic Anxiety: A Prospective Tertiary University Centre Cohort.
Borjon, A., Bobin, L., Ricordeau, F., Marces, L., Fornelli, H., Petitjean, T., Viccica, A., Charbonnier, E., Stauffer, E., Charbotel, B., et al. (2026) · Journal of Sleep Research · doi:10.1111/jsr.70423
Kızıldemir, Ö., Şengel, Ü., Çakmak, M., İbiş, S., & İNAN, R. (2026) · Journal of Hospitality and Tourism Technology · doi:10.1108/jhtt-07-2025-0560
Huang, Y., Dai, W., & Yang, Z. (2026) · Behavioral Sciences · doi:10.3390/bs16081318
“Emerging evidence suggests that the relationships among these variables may be both bidirectional and directional (Chellappa & Aeschbach, 2022; Kara¸s et al., 2023), highlighting a promising avenue for future research.”
Öktem, T., Akkuş, R., Öz, Ü., & Gök, U. D. (2026) · Frontiers in Psychology · doi:10.3389/fpsyg.2026.1901484
“It is the most common mental health problem worldwide (Chellappa and Aeschbach, 2022).”
Prise en charge de l’hypersomnolence
Christodoulou, N., Micoulaud‐Franchi, J., & Geoffroy, P. A. (2025) · Elsevier eBooks · doi:10.1016/b978-2-294-78711-9.00041-4
Speer, K. E., McKune, A. J., & Naumovski, N. (2026) · Exploratory Research and Hypothesis in Medicine · doi:10.14218/erhm.2025.00088
Spangenberg, L., Santangelo, P., Glaesmer, H., Forkmann, T., Eimen, J., Stengler, K., Strauß, M., & Brüdern, J. (2026) · Behaviour Research and Therapy · doi:10.1016/j.brat.2026.105143
How being ‘on-call’ for work can disrupt your sleep – even if the call never comes
Sprajcer, M. A., & Vincent, G. E. (2026) · doi:10.64628/aa.vgxgnqqvu
Ramos, M. S., Soto, P. F., Williams, C. D., Olivares, D., Macias, A., Rohan, J. M., León‐Pérez, G., Allison, K. W., Dautovich, N. D., Dzierzewski, J. M., et al. (2026) · Clocks & Sleep · doi:10.3390/clockssleep8030049
“In a review, Chellappa and Aeschbach [60] identified nonpharmacological interventions, such as lifestyle changes (e.g., reducing smoking, caffeine, alcohol, and drug use) and cognitive behavioral therapy for insomnia (CBT-I) as ways of enhancing sleep in individuals experiencing anxiety.”
Wu, Y., Wang, H., Wang, M., Ren, P., & Zhang, S. (2026) · Ultrasonics · doi:10.1016/j.ultras.2026.108282
Bellon, F., Targa, A., Loza, I. P., Abad‐Corpa, E., Rubinat, E., Orts‐Cortés, M. I., & Gea‐Sánchez, M. (2026) · Worldviews on Evidence-Based Nursing · doi:10.1111/wvn.70162
“However, this relationship may be confounded by the anxiety itself, which is known to contribute to poor sleep quality rather than being directly attributable to the type of intervention (Chellappa and Aeschbach 2022).”
He, L., Fang, Y., Luo, G., & Yu, L. (2026) · Complementary Therapies in Medicine · doi:10.1016/j.ctim.2026.103428
Zhong, D., Yang, L., Zhang, N., Zhang, Z., Yan, Y., Niu, S., Dong, J., Yelin, Y., Li, Y., Li, G., et al. (2026) · Research Square · doi:10.21203/rs.3.rs-10441569/v1
“Epidemiological studies show that sleep disturbances affect nearly 50% of individuals with an anxiety disorder (Chellappa and Aeschbach, 2022).”
Yan, X., Ma, Z., Zhang, Y., Zhou, Y., & Wang, C. (2026) · Health Communication · doi:10.1080/10410236.2026.2724342
Imazu, N., Naïto, K., SUZUKI, T., Kawamura, K., Itoh, T., & Ishijima, M. (2026) · The Journal of Hand Surgery (Asian-Pacific Volume) · doi:10.1142/s2424835526500517
Biological heterogeneity of melancholic, atypical, anxious, and psychotic depression
Nadei, O. V., & Ternovaya, E. V. (2026) · Progress in Neuro-Psychopharmacology and Biological Psychiatry · doi:10.1016/j.pnpbp.2026.111923
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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