What should be included in education for the client who reports insomnia due to increased stress?

2020 has been a stressful year for people in the U.S. According to results from the American Psychological Association’s Stress in America 2020 survey, general stress levels are significantly above average compared to years past. In fact, this year’s respondents reported the highest average stress levels since the survey was first launched in 2007 – 5.4 out of 10, an increase of 0.5 since last year. These figures can largely be attributed to COVID-19 and its implications on finances, parenting, and other aspects of daily life.

Stress and anxiety often lead to insomnia and sleep problems. By the same token, lack of proper rest can contribute to stress. And because stress and sleep problems share such a reciprocal relationship, addressing one of these issues can often lead to improvements for the other.

Stress and the Body

The network known as the hypothalamic-pituitary-adrenal (HPA) axis regulates your body’s hormonal response to stressful situations. The hypothalamus – a cluster of nuclei located in the brain – will instruct the pituitary gland to release a hormone, and then the pituitary gland will signal the adrenal glands to produce steroid hormones called glucocorticoids. Two of these glucocorticoids are cortisol and adrenaline, which are also known as stress hormones.

The body naturally produces cortisol throughout the day, with levels spiking immediately after we wake up and gradually decreasing throughout the day. This added cortisol regulated by the HPA is the reason why you often feel hyper-alert during stressful situations, but this can cause you to “crash” once the stress subsides.

Stress can take many forms, but these feelings generally fall into one of three categories:

• Acute stress: This type of short-term stress often accompanies fleeting moments of panic or dread. Examples include realizing you’ve missed a deadline for work or school, or nearly being involved in a car accident. You may notice upticks to your blood pressure and heart rate, followed by feelings of irritability, sadness, and anxiety. Some people also experience headaches, back pain, and gastrointestinal issues. However, the symptoms of acute stress typically subside after a short time.
• Episodic acute stress: This type of stress is essentially an accumulation of individual moments of acute stress. People who feel burdened by day-to-day struggles may attempt to alleviate their frustrations through unhealthy behaviors like overeating or binge drinking. Other serious complications of episodic acute stress include clinical depression and heart disease, as well as poor performance at work and relationship problems.
• Chronic stress: Many factors can contribute to chronic stress, including poverty, abuse, and trauma. People tend to internalize these painful experiences, and over time this can wear down the mind and lead to feelings of hopelessness. Chronic stress can also cause deficiencies related to how the HPA axis processes stressful situations and communicates with the rest of the body.

While moderate amounts of acute stress pose very little risk to your health, chronic stress can have a major impact on your body. These effects can be felt in various ways and throughout different bodily systems, including:

• Cardiovascular: The body’s “fight or flight” response to acute stress causes your heart rate and blood pressure to spike, and also increases contractions in your heart muscles. Cortisol and adrenaline act as messengers that regulate these functions. After the moment of acute stress is over, the body will stabilize. Chronic stress can cause long-term heart problems because your heart rate and blood pressure are constantly elevated, which puts added pressure on the cardiovascular system. This increases your risk for hypertension, heart attack, and stroke, and can also cause inflammation to your circulatory system.
• Gastrointestinal: The gut is loaded with nerves and bacteria that communicate with the brain in order to regulate mood and promote overall bodily health. Stressful moments can interfere with this communication, leading to pain, bloating, and other types of gastrointestinal discomfort. These situations can also lead to loss of appetite, which can have a negative impact on digestive health if it impacts what and when you eat. Obesity may also be an issue for people who overeat when they are anxious. Additionally, stress can weaken the intestinal barriers that prevent harmful bacteria from entering the stomach, and also cause painful spasms in the esophagus and bowels.
• Musculoskeletal: You may notice your muscles tensing up during stressful moments. This reflexive feeling is the body protecting you from potential pain or harm, and it is caused by dilating blood vessels in the arms and legs. Chronic stress can cause persistent muscle tension, which in turn may lead to other problems such as migraine headaches or lower back and upper extremity pain. In cyclical fashion, the discomfort of this constant tension can also contribute to long-term stress.
• Nervous: During moments of acute stress, the nervous system transmits signals between the pituitary gland and adrenal glands to facilitate production of adrenaline and cortisol. The nervous system also regulates the “comedown” period immediately following a temporarily stressful situation. Chronic stress can overwork your nerves and wear down the body over time.
• Reproductive: Stress can cause issues in the reproductive systems of men and women. Chronic stress can lead to diminished sexual desire for both sexes and leave them more vulnerable to cancers and other diseases that affect reproductive parts. Men may experience decreases in the size and swimming capabilities of their sperm, whereas women may have trouble conceiving. Chronic stress in pregnant women can also impact fetal and childhood development.
• Respiratory: Stressful situations can lead to both shortness of breath or rapid breathing. Acute stress may trigger asthma attacks and other problems for people with pre-existing respiratory conditions. Over time, chronic stress can lead to more serious conditions such as chronic obstructive pulmonary disease.

How Does Stress Affect Sleep?

Insomnia is a common sleep disorder derived from stress. Insomnia is defined as persistent difficulty with sleep onset, maintenance, consolidation, or overall quality. It occurs despite adequate time allotted for sleep on a given night and a comfortable place to sleep, and people with insomnia experience excessive daytime sleepiness, fatigue, irritability and other impairments when they are awake. Current estimates suggest 10-30% of adults live with insomnia.

A person may be diagnosed with chronic insomnia if their symptoms occur at least three times per week for at least three months. Persistent stressors can heavily contribute to chronic insomnia. These stressors may include:

• Problems or dissatisfaction at work
• Divorce and other marital or family difficulties
• The death of a loved one
• Major illness or injury
• Crucial life changes

Not everyone develops chronic insomnia due to constant stress, but those with anxiety disorder are at higher risk of experiencing insomnia symptoms. Additionally, changes to one’s sleep schedule that occur due to life events or changes can also lead to insomnia. Once chronic insomnia takes hold, people often feel anxious about sleeping and other aspects of their lives. This increases day-to-day stress, which in turn exacerbates insomnia symptoms.

Other daytime impairments related to insomnia that can bring about or contribute to stress include:

• Feelings of fatigue and malaise
• Difficulty paying attention, concentrating, or accessing memories
• Impaired performance in social, family, professional, or academic settings
• Irritability and mood disturbances
• Hyperactivity, aggression, impulsivity, and other behavioral issues
• Decreased energy and motivation
• Increased risk for errors and accidents

If someone experiences insomnia symptoms for fewer than three months, then this condition is referred to as short-term insomnia. Just as chronic stress can precipitate chronic insomnia, acute stressors can bring about short-term insomnia symptoms. These stressors may include:

• Interpersonal relationship issues
• Work-related problems
• Financial loss
• Grieving and bereavement
• Diagnosis or initial symptoms of a disease or other medical condition

Acute stress may also occur if you’ve made significant changes to your bedroom or sleep area. For example, new parents may experience insomnia symptoms when sharing their bedroom with their baby for the first time, even if the child is not audibly disruptive. Children may also have sleep problems immediately after they begin sharing their room with a sibling. Visiting or moving to a new location can lead to short-term insomnia, as well.

Short-term insomnia symptoms may begin to dissipate once the stressful situation ends and acute stress subsides. However, some people fall into a vicious pattern of sleep loss and daytime anxiety about sleep that eventually snowballs into chronic insomnia.

In addition to insomnia, chronic stress can lead to sleep apnea. This sleep disorder is characterized by a recurring collapse of the upper airway during sleep, which can cause heavy snoring and choking episodes along with excessive daytime sleepiness and other daytime impairments. Hypertension, heart disease, diabetes, and other medical conditions that can often be attributed to stress are predisposing factors for sleep apnea. Obesity is also considered a major risk factor. And like insomnia, sleep apnea can exacerbate stress by disrupting your sleep and wearing you down during the day.

Does Sleep Help Stress?

Getting enough sleep on a nightly basis can alleviate stress quite effectively. Unfortunately, a good night’s rest can be elusive if you’re stressed out – especially if sleep problems are a major source of your day-to-day anxieties.

There are other measures you can take to relieve stress. These include regularly exercising and maintaining a healthy support network of friends and family. However, keeping stress at bay often demands adequate sleep. National Sleep Foundation guidelines advise that healthy adults should sleep between seven and nine hours each night.

How to Sleep When Stressed

Stress management is key to a good night’s sleep, and how well you manage stress can depend on your day-to-day lifestyle. In addition to following a balanced diet and exercising throughout the week, you can alleviate stress through controlled breathing and other relaxation techniques. A healthy work-life balance is also important, as is your ability to productively “release” stress during situations that cause stress, and not at other moments.

Proper sleep hygiene can also improve your sleep quality and duration, leaving you more refreshed in the morning and prepared to manage stress. Sleep hygiene guidelines include:

• Strict sleep schedule: Go to bed and wake up at the same times each day. This includes on the weekends and when you’re traveling or on vacation.
• Optimal bedroom atmosphere: Your bedroom should have a relaxing effect when you are ready for sleep. You should keep the lights dim and reduce exposure to outside noise. A comfortable temperature is also key; experts generally recommend 60 to 67 degrees, though 65 degrees is considered the ideal.
• No electronics: Televisions, computers, cell phones, and other electronic devices emit a blue light that can interfere with sleep. For best sleep results, keep these devices out of your bedroom at all times.
• Reduced evening intake: Avoid consuming nicotine and caffeine in the hours leading up to bedtime. These stimulants can keep you feeling alert when it’s your normal time for sleep. Alcohol can also be problematic for sleep. Many people think drinking helps sleep because of alcohol’s sedative properties, but you may experience sleep fragmentation as your body processes and breaks down the alcohol. Lastly, you should avoid large meals before bed.
• Regular exercise: Moderate exercise in the morning or early afternoon can help you wind down and fall asleep more easily at night.

Laying in bed when you are too stressed to sleep can be counterproductive. If you haven’t gone to sleep within 15 minutes of going to bed, try getting up and relocating to another area of your residence for a relaxing activity such as reading, meditating, or listening to calming music; avoid watching TV or other activities that involve blue light devices.

Some people also experience anxiety when they wake up in the middle of the night and see the time on their bedside clock. Avoid looking at your clock if you wake up – cover the display if necessary.

If your sleep problems persist, you should see your doctor or another credentialed physician. This may lead to an insomnia diagnosis and treatment for your insomnia symptoms.

Other Stress Management Tips

Some people find stress relief through cognitive behavioral stress management (CBSM). This form of short-term therapy pinpoints the way your thoughts and beliefs affect how you behave and interact with the world around you. By identifying irrational or inaccurate thoughts and replacing them with more positive ones, you may be able to change your behaviors and your general outlook.

Studies have shown CBSM can be an effective measure for various groups that tend to experience undue stress, such as professional nurses, people with substance abuse disorders, and individuals living with HIV.

Incidentally, cognitive behavioral therapy has also proven effective for alleviating insomnia symptoms. Known as CBT-i for short, this type of therapy helps people overcome misconceptions or negative beliefs about sleep in order to get more rest and overcome their insomnia. CBT-i emphasizes sleep restriction and the importance of getting out of bed on sleepless nights, as well as proper sleep hygiene and relaxation techniques.

In addition to following sleep hygiene guidelines and pursuing CBSM therapy, many people effectively manage their stress by taking the following measures:

• Learn to recognize stress: Stress elicits different reactions from everyone. They may include trouble sleeping, dependence on alcohol or drugs, feelings of irritability and  anger, or low levels of energy and motivation. Recognizing these reactions is key to understanding when you’re stressed.
• Engage in relaxing activities: When performed correctly, meditation, muscle relaxation, and controlled breathing exercises can all help alleviate stress. Incorporating these wellness activities into your regular routine can reduce stress to a significant degree.
• Create goals for yourself: Giving up and not caring about what comes next are hallmarks of desperation. Stress, especially at the chronic level, can induce these negative feelings. Maintain a positive mindset by setting reasonable goals in your social, family, and professional life.
• Reach out to your support system: Maintaining consistent communication lines with your friends and family members can reduce stress through emotional support. Some people also find comfort through connecting with community groups and religious organizations.
• Initiate the “stress talk” with your doctor: Stress, when unchecked, can quickly become overwhelming. Take a proactive approach toward stress management by scheduling an appointment with your doctor or mentioning stress during your next checkup.

You should see your doctor or another physician immediately if you’re experiencing suicidal thoughts, abusing drugs or alcohol, or feeling that you can’t cope with day-to-day life due to stressors. You can also call the National Suicide Prevention Lifeline at 1-800-273-8255 (1-800-273-TALK). The lifeline also offers 24-hour live online chat on their website, as well.

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