The Bidirectional Relationship Between Sleep Disturbance and Exposure-Based Treatment for Social Anxiety Disorder: A Multi-Method Examination

Background . Individuals with Social Anxiety Disorder (SAD) often experience poor sleep, which may influence treatment outcomes. Although theoretical models link sleep and fear extinction mechanisms, findings are equivocal and largely based on subjective measures. This study investigates the bidirectional relationship between sleep (duration, efficiency, quality) and outcomes from exposure-based SAD therapy. Methods . Participants (N = 32) with SAD completed five weeks of exposure-based group therapy. Daily sleep data (self-report and actigraphy) were collected pre-, during, and post-treatment. The Liebowitz Social Anxiety Scale (LSAS) assessed treatment outcomes. Multilevel modeling examined associations between sleep and treatment outcomes. Results . Treatment significantly impacted sleep such that nights after therapy were associated with reduced actigraphy-based sleep duration and participants with poor baseline sleep exhibited post-treatment improvements in sleep quality and efficiency (self-report and actigraphy). While poor baseline sleep quality and actigraphy sleep duration were associated with greater baseline symptoms, they did not predict changes across treatment. Sleep before and after exposure sessions also did not predict SAD symptoms. Conclusions . Findings suggest exposure-based SAD treatment influences sleep, particularly in poor sleepers, but that poor sleep does not hinder treatment efficacy. Additionally, clinicians may consider informing patients about potential post-exposure sleep disturbances to support engagement.