COVID-19 frequently disrupts sleep, both during the acute illness and as a lingering symptom afterward. Sleep problems are a widely reported health effect, with studies indicating that around half of all individuals who contract the virus experience some form of sleep disturbance. This issue represents a complex interplay of physical symptoms, psychological stress, and direct biological effects of the virus on the body. Understanding the acute versus persistent phases of this sleep disruption helps clarify the nature of the problem and guides management.
Sleep Disturbances During Acute Infection
During the active phase of the illness, which typically lasts the first few weeks, sleep disruption is often a direct result of the body’s response to the viral invasion. Physical symptoms like fever, persistent coughing, and body aches make it difficult to find a comfortable position or maintain sleep continuity. Nasal congestion and shortness of breath can also interfere with breathing patterns during the night, leading to frequent awakenings.
Beyond the physical discomfort, acute psychological factors contribute significantly to sleeplessness during infection. The stress and anxiety related to a new diagnosis, the fear of disease progression, and the uncertainty of isolation can trigger a state of hyperarousal. This heightened alertness and worry is physiologically incompatible with the relaxation needed to fall asleep and often results in difficulty initiating sleep. For many, these acute sleep disturbances resolve as the primary symptoms of the infection clear.
Persistent Insomnia and Long COVID
Sleep issues often become a chronic condition associated with Long COVID, also known as Post-Acute Sequelae of SARS-CoV-2 (PASC), after the acute infection has passed. Estimates show that sleep disturbances persist for weeks or months in over 40% of patients following the initial illness. These chronic problems include severe insomnia, fragmented sleep, and non-restorative sleep that leaves a person unrefreshed despite a full night in bed.
Persistent sleep problems include difficulty falling asleep (sleep onset insomnia) and trouble staying asleep (sleep maintenance insomnia). Some individuals also experience excessive daytime sleepiness. Furthermore, some patients develop new-onset circadian rhythm disorders, where the body’s internal clock is shifted, leading to an irregular sleep-wake cycle. These chronic disruptions severely impact daytime functioning, contributing to the fatigue and cognitive symptoms commonly reported in Long COVID.
Biological Factors Driving Sleep Disruption
The persistence of sleep problems is often rooted in the underlying biological changes triggered by the virus, not just behavioral factors. One primary mechanism is systemic inflammation, characterized by the sustained elevation of pro-inflammatory signaling molecules like Interleukin-6 (IL-6) and Tumor Necrosis Factor-alpha (TNF-α). These cytokines, which are normally part of the immune response, can interfere directly with the brain regions that regulate the sleep-wake cycle. This disruption essentially creates a pro-inflammatory state that promotes wakefulness and hinders deep, restorative sleep.
The virus also appears to impact the central nervous system through a process called neuroinflammation. While the virus may not directly infect all brain cells, the resulting inflammation can compromise the integrity of the blood-brain barrier. This allows inflammatory mediators and other stress-related chemicals to enter the brain, damaging neuronal function and altering the signaling pathways that govern sleep.
Further complicating the issue is the dysregulation of the autonomic nervous system (ANS), the body’s involuntary control center. The ANS controls functions like heart rate, breathing, and the fight-or-flight response. Post-infection, many patients show signs of sympathetic nervous system overactivity, leading to a state of chronic hyperarousal. This constant, low-level activation, evidenced by elevated stress hormones like norepinephrine and cortisol, makes it physiologically difficult for the body to settle into a sleep state, contributing to chronic insomnia.
Managing COVID-Related Sleep Problems
Addressing persistent sleep problems requires a structured approach, beginning with the implementation of sleep hygiene practices. Establishing a consistent sleep schedule, even on weekends, helps to strengthen the body’s natural circadian rhythm. Limiting light exposure from screens and ensuring the bedroom environment is dark, quiet, and cool promotes optimal conditions for sleep initiation.
When sleep difficulties become chronic, professional intervention is necessary, often starting with behavioral therapies. Cognitive Behavioral Therapy for Insomnia (CBT-I) is considered the most effective non-pharmacological treatment, focusing on changing the thoughts and behaviors that perpetuate sleeplessness. Techniques such as stimulus control and sleep restriction are used to re-associate the bed with sleep and consolidate the time spent resting.
For those with severe or complex sleep disturbances, medical consultation is an important next step. A primary care physician can screen for underlying conditions like sleep apnea, which may be exacerbated by the infection, and determine if referral to a sleep specialist or neurologist is appropriate. While medications can offer temporary relief, the focus remains on long-term behavioral changes, with pharmacological approaches generally reserved as a last resort due to the potential for dependence or side effects.