If you live with a chronic pain or inflammatory condition, this pattern may feel familiar. You are exhausted, but come bedtime your mind is still going, replaying the day, running through tomorrow, or focusing on how your body feels. Pain and sleep have a two-way relationship: disrupted sleep can heighten pain sensitivity, and pain or worry about pain can make it harder to switch off at night. The more you worry about not sleeping, the harder sleep can become to reach.
Understanding what is happening in your brain and body when this cycle takes hold can help you respond differently, rather than lying there waiting for sleep to arrive.
Being physically tired while your mind refuses to settle is a common experience, and it can be especially difficult when you are already managing pain, a chronic health condition or other demands that make a good night's sleep feel even more important.
Anxiety is your brain's response to a perceived or actual threat. That threat does not have to be immediate or physical. Uncertainty about the future, social situations, fear of making mistakes or worrying about whether you will cope tomorrow can all trigger the same response.
When anxiety kicks in, your fight-or-flight system activates. Your heart rate can increase, you may feel restless and your mind can become more alert. Your body is essentially preparing you to respond to something it perceives as a threat, which makes sense when you need to deal with danger. It is less helpful when you are lying in bed trying to sleep.
Sleep itself can become the thing you worry about. You might find yourself thinking, "What if I can't cope tomorrow?", "What if I fail?" or simply, "Why can't I sleep?" These thoughts create frustration, which increases alertness. You then remain awake, become more concerned about not sleeping and put even more pressure on yourself to fall asleep. This is how worry, physical alertness and poor sleep can end up reinforcing one another.
Sleep is not something you can force by trying harder. It relies partly on sleep pressure, which builds the longer you are awake and active during the day.
This is why some common attempts to recover from a poor night's sleep can have the opposite effect. Sleeping in late, taking long daytime naps or going to bed much earlier can reduce the sleep drive you have when the next night arrives. A more useful focus is consistency rather than perfection.
Choose a wake time you can keep most days, even after a poor night's sleep. Pair it with simple morning cues, such as opening the blinds, moving around, showering or making the bed. Build in some daytime movement to use energy during the day. If you nap, keep it short and separate from bedtime where possible, and consider reducing caffeine. Go to bed when you are actually ready to sleep. None of this is about rigid rules, it is about giving your body enough opportunity to build sleep pressure naturally.
Over time, the bed can become associated with things other than sleep, lying there worrying, watching the clock, scrolling on your phone or counting down how little time is left before morning. Your brain can start to link getting into bed with being awake and worried, rather than with sleep.
Notice what your bed has become a cue for. If you are not feeling sleepy after roughly 15 to 30 minutes, get out of bed. Read, move around or sit somewhere in low light, then return to bed when you feel sleepy again. Keep your usual wake time rather than trying to compensate by sleeping in.
It can be tempting to go to bed much earlier after several nights of broken sleep, but if you are spending 10 hours in bed while only sleeping for five, adding more time in bed may not solve the problem. These strategies can feel counterintuitive, but the aim is to retrain the cues around sleep so your bed becomes a stronger signal for sleep rather than wakefulness.
Worries often become louder once the day goes quiet. Your brain may start running through tomorrow's appointment, an upcoming conversation or something you are uncertain about, often because it is trying to protect you.
One strategy is to "park" those worries rather than trying to solve everything at bedtime. Write the worrying thought down in one sentence, for example, "I'm worried about my appointment tomorrow." Then ask yourself, can I solve this right now? If yes, write down one small action you can take tonight. If no, write down that it is not solvable tonight, for example, "Not solvable, I cannot solve this at 2am." Then close the notebook. Writing the thought down does not make the problem disappear, but it acknowledges the concern and gives your brain permission to put it aside for now.
Simple strategies can also help calm your nervous system through the day and before bed, including exercise, time in nature, gentle stretching, meditation, a warm shower and a consistent routine. Reducing screen time, bright lights and loud noises before bed can help too. Your environment matters as well: dim lighting, a tidy and uncluttered space, clean clothes and bed sheets, a comfortable room temperature and fewer distractions can all support a sense of physical and psychological safety.
It can be hard to notice when something you are doing to help yourself has become something you feel you cannot do without. These are known as safety behaviours: behaviours aimed at preventing or avoiding something you fear.
When it comes to sleep, this might look like going to bed much earlier to "catch up", following an excessively long bedtime routine, relying heavily on relaxation exercises to make yourself sleep, napping, or reducing your social and physical activities because you are worried about being tired. These behaviours are understandable. After a difficult night, it makes sense to want to protect yourself from another one.
Some safety behaviours can reduce sleep pressure or maintain anxiety around sleep, and they can prevent you from learning that you may be able to sleep, or cope with a poor night, without relying on a particular behaviour. For example, if you believe, "If I don't do my two-hour relaxation routine, I won't sleep," then a night when you do sleep may reinforce the belief that the routine caused it, making the routine feel increasingly necessary.
It can help to gradually consider whether a particular behaviour is genuinely helping your sleep, or whether it has become something you feel you must do to prevent a feared outcome.
When sleep has become a source of worry, it is understandable to want to fix it immediately. But putting more pressure on yourself to sleep can increase alertness and make settling harder. Rather than changing everything at once, choose one thing to experiment with.
You might keep the same wake time each day, increase your daytime movement, reduce caffeine, write down your worries before bed, or create a simple wind-down routine. You might also try changing what you do when you are awake in bed, or consider whether there is a safety behaviour you could gradually let go of.
If you are living with pain or a chronic health condition, sleep can also be affected by your broader physical and emotional wellbeing, so looking at sleep in isolation may not always tell the whole story. Your healthcare team can help you consider how different parts of your health may be interacting and where additional support could be useful.
You do not have to solve everything in one night. Sometimes, changing the cycle starts with understanding what your brain and body are trying to do, then making one small change that gives them a different cue.
Sleep can become complicated when the worry about not sleeping becomes part of the problem. By building sleep pressure during the day, creating clearer sleep cues, calming your nervous system and reconsidering behaviours that maintain anxiety, you can begin to change that cycle. The aim is not perfect sleep every night, but a more consistent and less anxious relationship with sleep.
This article is based on psychologist Adrian Comensoli’s talk on "Sleep and the Anxious Brain”. You can watch the full session and hear his complete insights by watching the full talk here.