Can’t sleep with OCD? Here’s what actually helps

Obsessive-compulsive disorder (OCD) is often associated with rituals, intrusive thoughts, and hypervigilance. But one of its most overlooked, and clinically disruptive, features is chronic sleep disturbance.

Sleep is not simply disrupted by the anxiety and behaviours typical of OCD; it is entangled with the disorder’s underlying neurobiology. Research indicates that approximately 42 percent of individuals with OCD exhibit signs of delayed sleep-wake phase disorder (DSWPD), with melatonin onset occurring up to 2.3 hours later than in healthy controls (Robillard et al., 2013; Tükel et al., 2012).

While prevalence rates vary across studies, they consistently show significantly higher rates of DSWPD in OCD compared to the general population. This circadian misalignment contributes to a pattern of late-night rumination, delayed sleep onset, and impaired daytime functioning.

The OCD-Sleep Vortex: Mechanistic Pathways

Why does OCD have such a significant negative impact on sleep? There are a few factors at play:

1. Intrusive Thoughts and Cognitive Hyperarousal

Obsessions, defined as recurrent, unwanted thoughts or urges, are a core component of OCD and a major contributor to sleep onset insomnia. Functional neuroimaging has demonstrated increased activity in the amygdala and anterior cingulate cortex (ACC) among individuals with OCD, areas implicated in error detection and threat monitoring (Harrison et al., 2009). At night, when external distractions are reduced, this hyperactivation fosters cognitive hyperarousal, delaying sleep and fragmenting rest (Nota et al., 2015).

2. Compulsions and Prolonged Sleep Latency

Bedtime is also a peak window for compulsive behaviours such as checking locks, reviewing events, or arranging objects symmetrically. In a large clinical study, nearly two-thirds of patients with OCD reported engaging in compulsions immediately before bed, directly contributing to delayed sleep initiation (Abramowitz et al., 2018). These rituals, though intended to reduce distress, reinforce anxiety and disrupt circadian cues linking bedtime with rest.

3. Circadian Dysregulation

Beyond behavioural patterns, individuals with OCD often show biological markers of circadian dysregulation. Delays in dim light melatonin onset (DLMO) have been reported in both adult and pediatric OCD populations, suggesting an underlying shift in sleep-wake timing (Robillard et al., 2013). This misalignment is not only associated with delayed sleep but has also been linked to increased symptom severity and poorer therapeutic outcomes (Hasler et al., 2016).

4. Repetitive Negative Thinking and Bidirectionality

Recent studies show that repetitive negative thinking (RNT), a hallmark of OCD, is worsened by sleep loss, which impairs prefrontal regulation and executive functioning (Frontiers in Psychology, 2023). This suggests a bidirectional feedback loop where OCD symptoms and poor sleep perpetuate one another, underscoring the clinical urgency of addressing both together.

5. The Potential Role of Comorbidities

Comorbid anxiety and depression are common in OCD and can independently disrupt sleep. However, studies using polysomnography and mediation analysis confirm that sleep disturbances persist even when controlling for these variables, supporting the view that sleep dysfunction is intrinsic to OCD (Nota et al., 2015).

OCD-Specific Interventions to Restore Sleep

If you have OCD and struggle to get to sleep, these approaches may help:

1. ERP-Adapted Sleep Routines

Exposure and response prevention (ERP) remains the gold-standard intervention for OCD. Adaptations for nighttime rituals include gradually delaying compulsions and tolerating anxiety without engaging in the behaviour. Abramowitz et al. (2018) demonstrated that ERP focused on bedtime compulsions reduced sleep onset latency by over 60 percent in patients with severe OCD.

2. Mindfulness and Scheduled Worry Time

Cognitive strategies targeting metacognitive beliefs about obsessions have shown promise in reducing nighttime rumination. Mindfulness-based cognitive therapy (MBCT) enables patients to observe intrusive thoughts non-judgmentally, decreasing their emotional salience. Wahl et al. (2020) reported significant reductions in presleep arousal through mindfulness and paradoxical intention strategies. Similarly, structured worry periods scheduled earlier in the evening have been shown to externalise concerns, reducing pre-sleep cognitive load (Hoyer et al., 2007).

3. Light-Based Circadian Interventions

Circadian misalignment in OCD can be partially corrected using phototherapy. Hasler et al. (2016) and the AASM Foundation (2025) demonstrated that timed morning light exposure combined with evening use of blue-light blockers advanced sleep onset and improved OCD symptom scores. These findings support the integration of chronotherapy into multimodal OCD treatment plans, particularly for patients with comorbid DSWPD.

5. CBT-I with OCD Modifications

Although cognitive behavioural therapy for insomnia (CBT-I) is the frontline treatment for chronic insomnia, it requires modification in OCD populations. Rigid sleep scheduling, a key component of CBT-I, may exacerbate compulsive tendencies. Flexible sleep windows and adjusted stimulus control protocols—such as leaving the bed during wakefulness but avoiding compulsive behaviours like checking sleep apps—may be more effective (Hohagen et al., 1994).

6. Pharmacologic Adjustments

Sleep disturbances may also be mediated by medication side effects. While selective serotonin reuptake inhibitors (SSRIs) are first-line pharmacotherapy for OCD, they can exacerbate insomnia when taken at night. Reinhold et al. (2015) reported improved sleep outcomes when SSRIs were administered in the morning. Adjunctive use of low-dose sedating agents, such as trazodone, has also been supported in treatment-refractory cases (Mendelson, 2005).

Clinical Considerations and Screening

Given the high prevalence of sleep disruption in OCD, routine screening for sleep issues should be standard clinical practice. Tools such as the Pittsburgh Sleep Quality Index (PSQI) and actigraphy can help identify patterns of insomnia, delayed sleep phase, and sleep fragmentation, enabling more targeted interventions (Sleep Medicine Reviews, 2022).

For individuals with OCD, sleep is not merely disrupted by anxiety, it is actively entangled with the disorder’s neurobiological, behavioural, and circadian dysfunctions. By integrating ERP, circadian regulation, cognitive restructuring, and targeted pharmacotherapy, clinicians can address both the symptoms of OCD and the sleep disturbances that sustain them.