Recent research shows that daytime thoughts can interfere with sleep just as much as nighttime thoughts.
Most patients are well aware that anxious thoughts at bedtime can keep them up at night. Recent research also shows that it is not just nighttime thoughts that interfere with sleep—daytime thoughts can interfere with sleep as well. Additionally, anxious thoughts involve several distinct features. Worry and rumination are specific types of anxious thoughts. While they often coexist and have some similar features, worry and rumination are not the same, and they each independently impact insomnia.
Patients often do not seek professional help for managing anxious thoughts. However, many patients do seek help to get treatment for symptoms of fatigue, sleepiness, low energy, and other effects of sleep deprivation. While these issues can be caused by medical problems that should be ruled out, like anemia and heart disease, insufficient sleep due to insomnia is a common cause of daytime symptoms.
Daytime sleepiness caused by insomnia can manifest with difficulty concentrating, diminished ability to multitask, impaired emotional regulation, and falling asleep during activities such as meetings and driving. Objective sleep measures may also reflect shortened daytime sleep latency.
A research study involving 459 adults published in Behavioral Sleep Medicine considered worry and rumination as 2 separate constructs, a distinction that had been established in previous literature. Worry is thinking about future events that may have undesirable outcomes, particularly if there are factors that a person may not be able to control. Rumination involves recurrent negative thoughts and can include repeatedly thinking about problems or events (usually negative events), especially those that have happened in the past and cannot be changed. Using patient self-reports, the researchers found that each of these factors individually contributes to daytime sleep-related impairment. Furthermore, analysis specifically showed that worry was a predictor of sleep disturbance, and that rumination predicted sleep-related daytime impairment.1 This suggests that each of these may have a different impact on patients’ sleep, and that each is important enough to be addressed independently.
Traditionally, insomnia is thought to be associated with nighttime thoughts. However, daytime worry and rumination may affect sleep as well. A small research study involving 27 insomnia patients and 20 healthy controls published in Sleep Medicine found a significant relationship between daytime levels of repetitive thought and participants’ sleep using objective sleep measures obtained by polysomnography. The researchers reported that heightened worry levels were related to an augmented wake after sleep onset and a diminished total sleep time, reduced sleep efficiency, and lower percentage of REM sleep. They also found that rumination was associated with an increase of sleep latency and a decrement of sleep efficiency.2
The impact of daytime thoughts on nighttime sleep suggests that strategies for reducing worry and rumination at the time of sleep might not be enough to alleviate insomnia. To have a greater impact, strategies to reduce worry and rumination can also address the problems of anxious daytime thoughts. Several approaches are used to manage worry and rumination. Habits that help with problem solving and with providing a frequent sense of closure can reduce rumination and worry and may help alleviate anxious daytime thoughts. Additionally, rumination-focused cognitive behavioral therapy can be administered by a qualified therapist. This can relieve symptoms of rumination and has been used as a treatment for different age groups.3 Treatments using a mobile app may be effective for helping patients who have these problems as well.4
In general, worry and rumination are not uncommon, and they can affect patients who do not have a psychiatric condition. Most patients recognize the effects of nighttime anxious thoughts on their sleep. But the impact of daytime anxious thoughts on sleep are not as well-known and are often ignored in the management of insomnia. For many patients, awareness of this interaction is a first step in alleviating the problem. The key component to resolving the issue is to provide patients with tools to help them manage their recurrent thoughts during both their waking hours and their sleeping hours. This often involves instruction and therapy, as it can be difficult for patients who are experiencing anxious thoughts to create solutions in the midst of anxiety-provoking circumstances, or when they are distracted by recurrent thoughts.
Dr Moawad is associate editor, Humanities in Neurology; clinical assistant professor, Case Western Reserve University School of Medicine, Division of Medical Education; and editor in chief emeritus of Neurology Times (2017-2019).
1. Tutek J, Gunn HE, Lichstein KL. Worry and rumination have distinct associations with nighttime versus daytime sleep symptomology. Behav Sleep Med. 2021;19(2):192-207.
2. Galbiati A, Giora E, Sarasso S, et al. Repetitive thought is associated with both subjectively and objectively recorded polysomnographic indices of disrupted sleep in insomnia disorder. Sleep Med. 2018;45:55-61.
3. Cook L, Watkins E. Guided, internet-based, rumination-focused cognitive behavioural therapy (i-RFCBT) versus a no-intervention control to prevent depression in high-ruminating young adults, along with an adjunct assessment of the feasibility of unguided i-RFCBT, in the REducing Stress and Preventing Depression trial (RESPOND): study protocol for a phase III randomised controlled trial. Trials. 2016;17:1.
4. Edge D, Newbold A, Ehring T, et al. Reducing worry and rumination in young adults via a mobile phone app: study protocol of the ECoWeB (Emotional Competence for Well-Being in Young Adults) randomised controlled trial focused on repetitive negative thinking. BMC Psychiatry. 2021;21(1):519.