Sleep and Stress

Table of Contents

Stress is an important part of human biology that allows people to react quickly and decisively in the face of challenging or dangerous situations. However, too much stress can have a profound impact on sleep and overall health.

Surveys suggest the stress of the COVID-19 pandemic has taken a significant toll on sleep quality, with one study finding that 41% of people experienced negative changes to their sleep quality in large part due to COVID-related stress.

We examine how stress levels can affect sleep quality and how poor sleep in turn can affect stress levels. We also provide actionable advice on how to manage stress and improve sleep habits.

Stress represents the body’s physiological and mental response to a threat.

When faced with a stressful situation, the brain triggers the fight-or-flight response, which starts with the release of hormones like adrenaline. These hormones cause a rise in blood pressure, muscle tension, breathing and heart rate, and blood sugar, as well as higher levels of alertness, decreased sensitivity to pain, and slowed digestion. All of these changes are intended to help a person face a challenge head-on or escape to safety.

The second part of the stress response involves a cascade of hormones including cortisol, which is released in high amounts during times of stress. Cortisol directs energy away from processes that are not urgent, such as wound healing and immune system functioning, to help the body prepare to fight an immediate attacker.

From an evolutionary point of view, stress is a useful tool. The fast-acting stress response help us evade threats and avoid accidents. However, exposure to prolonged and repeated stressors such as relationship issues or financial worries leads to chronic stress, which can take a significant toll on health. This is why it is important to identify and address common triggers and sources of stress in daily life.

Stress and sleep have a reciprocal relationship. High levels of stress can contribute to trouble sleeping, and poor-quality or insufficient sleep can lead to maladaptive changes to the stress response. Understanding the connection between stress and sleep is the first step to breaking this frustrating loop.

How Stress Affects Sleep

Chronic stress causes dysregulation of the sleep-wake cycle, the internal clock that tells the body when it is time to sleep and when it is time to be alert. When people experience stress during the day, they are more likely to have trouble falling asleep and report poor sleep quality that night. Stress may reduce deep sleep and rapid eye movement (REM) sleep, both of which are important for mental and physical health. Stress can color the patterns and emotional content of dreams.

The level of the stress hormone cortisol has important implications for the sleep-wake cycle. While cortisol usually decreases at night in preparation for sleep, studies have found that people with insomnia have higher levels of cortisol in the evening, which are linked in turn to a greater number of nighttime awakenings. However, more research is needed to know whether high cortisol levels cause insomnia or whether sleep problems increase cortisol levels.

Some researchers have defined one cause of short-term insomnia as a response to a stressful event, seeing the inability to sleep as a natural reaction to a potential threat. The fight-or-flight response enacts immediate physiological changes that may make it hard to sleep, including:

• Muscle Tension: One of the hallmarks of the stress response is muscle tension. The major muscle groups in the body tense up in anticipation of potential harm or pain. But too much tension can interfere with the relaxation needed for peaceful sleep.
• Elevated Heart Rate: An elevated heart rate and rapid breathing are common signs of stress. However, sound sleep requires the opposite – slowed heart rate and breathing.
• Digestive System Effects: Excessive stress can affect the digestive system, often causing an upset stomach, diarrhea, or constipation that may be uncomfortable when trying to sleep.

The good news is that while more stress can lead to worse sleep, the reverse also seems to hold true. One study found that ruminating on stressful events, rather than higher levels of stress per se, was the primary factor affecting sleep quality. Finding ways to cope with stress may reduce the negative effects of stress on sleep, even for those with high-stress lifestyles. Studies have also found that sleep can improve quickly after a temporary stressor ends.

How Sleep Affects Stress

Not getting enough sleep has a significant impact on stress levels and overall mood. Research suggests that people who have slept better also experience less negative emotions and can recover faster from a stressful event.

On a biological level, poor sleep quality and sleep deprivation are thought to influence stress-related parameters including cortisol levels and systemic inflammation. Fragmented sleep or long-term sleep deprivation appear to contribute to higher cortisol levels. Going to sleep at times that are not concordant with natural sleep-wake rhythms can also disrupt cortisol patterns.

Stress and Sleep During the Pandemic

According to a survey released by the American Psychological Association, 2 in 3 adults reported experiencing increased stress levels during the COVID-19 pandemic, and approximately 40% of people have experienced sleep problems. Globally, people are also experiencing high rates of depression, anxiety, and distress, and one study found that people who were infected with COVID-19 were more likely to have nightmares.

Changing work and social parameters have more people working from home, taking on a higher workload, struggling to find a job, or spending more time on childcare. Stress, uncertainty, and health-related worries, coupled with restrictions on cultural events or socializing with friends and family, can all influence sleep. Sleep problems may be further increased when the home takes on the role of an office, daycare, and bedroom, which might prevent the bedroom from being used exclusively for sleep and sex.

For some people, the pandemic may have brought positive changes, such as the widespread adoption of technology that makes socializing easier, the lack of a commute, flexible work hours that can be better adapted to morning or evening preferences, and a greater incentive to go outside and exercise. Learning to leverage these changes as the pandemic evolves may lead to healthier lifestyle patterns and better sleep in the future.

Sleep disorders can affect sleep quality, quantity, or timing, or cause unusual behaviors during sleep. Two of the most common sleep disorders, insomnia and sleep apnea, may be closely related to stress.

Insomnia

Stress is a key risk factor for insomnia, which refers to trouble falling asleep, staying asleep, or waking up too early. People with insomnia may feel unrefreshed when waking up and experience next-day sleepiness. Up to 50% of all adults report symptoms of insomnia at some point in their lives.

Individuals going through stressful events and those who have a hard time coping with stressors are more likely to experience chronic insomnia. Insomnia is considered chronic once it persists for more than three months. Insomnia also has a strong link with mental health disorders, including anxiety, depression, and post-traumatic stress disorder. Over time, insomnia itself may lead to anxiety surrounding sleep, compounding the problem.

Researchers are starting to gain a better understanding of the link between stress and insomnia. A primary factor is sleep reactivity, or how much stress impacts your sleep. Some individuals have low sleep reactivity, meaning they do not experience sleep disturbances in response to stress. By contrast, individuals with high sleep reactivity tend to experience a significant decline in sleep quality when faced with stressful situations. As a result, people with higher sleep reactivity are more vulnerable to stress-induced insomnia.

Sleep Apnea

Obstructive sleep apnea occurs when the upper airway becomes momentarily blocked during sleep, causing partial or complete lapses in breathing that lead to mini-awakenings throughout the night. People with sleep apnea are more likely to have high stress levels, regardless of the severity of their apnea symptoms. Researchers theorize that nighttime awakenings from obstructive sleep apnea might contribute to higher stress hormone levels, but more research is needed.

Those with sleep apnea and chronic stress may also experience changes to mental pathways that predispose them to anxiety and depressive symptoms. Some researchers have proposed that the periodic lack of oxygen from sleep apnea may be partly responsible for these changes.

Sleep apnea also appears to have a close relationship with post-traumatic stress disorder (PTSD), characterized by permanently high stress levels following a traumatic event. PTSD generally makes it difficult for people to relax. This may lead to lighter, fragmented sleep in which the sleeper is more sensitive to physical changes in the airway. Similarly, people with PTSD often experience nightmares, which may be exacerbated due to sleep apnea’s effect on sleep quality. Researchers have found that treating sleep apnea can help ease PTSD symptoms.

Stress reduction may have a beneficial effect on sleep quality and vice-versa. We address how to sleep better when stressed, and how to manage stress to enhance sleep.

As there is no one-size-fits-all solution to managing stress and improving sleep, individuals may need to experiment with different approaches and work with a medical professional to find the best solution for their needs.

Tips to Sleep Better When Stressed

Implementing sleep hygiene techniques may help improve sleep during times of stress:

• Save Your Bed for Sleep: To strengthen the mental associations of the bed with relaxation and sleep, sleep experts recommend reserving the bed for sex and sleep only. Keep the bedroom cool, dark, and quiet, and avoid working, eating, and watching TV in the bedroom. Do not go to bed until you feel sleepy.
• Do Not Watch the Clock: Refrain from looking at the time if you wake up during the night.
• Schedule Stress Time: It may help to schedule worry time at a set time every day, earlier in the day. This provides the opportunity to write down or talk through concerns, and shift negative feelings away from bedtime.
• Avoid Caffeine Later in the Day: Caffeine consumption can make it harder to fall asleep, even when taken a full six hours before bedtime. Try to limit your intake to the morning and early afternoon.
• Avoid Alcohol and Tobacco: Consuming alcohol and tobacco within four hours of bedtime can have a negative effect on sleep quality.
• Keep a Consistent Sleep Schedule: Waking up and going to sleep around the same time every day may make it easier to fall asleep and contribute to longer sleep time and better sleep quality. If possible, try to choose a bedtime and wake-up time that fits your natural inclinations, depending on whether you are an early bird or a night owl.
• Manage Light Exposure: Regular exposure to sunlight during the day, especially in the morning, can help regulate the internal sleep-wake clock. Along the same lines, it is best to avoid bright artificial lights in the evening close to bedtime, as these can make it harder to fall asleep.
• Stay Active: Regular exercise may help reduce stress and improve mood, as well as improve sleep quality and duration. Exercising in daylight generally provides the most benefits for sleep. Evening exercise can still have a positive effect on sleep for many people, but it is best to avoid vigorous workouts an hour or less before bedtime.

How to Manage Your Stress for Better Sleep

General sleep hygiene is crucial, but managing stress may be just as important. Certain changes may help you control your stress to improve sleep quality:

• Limit Your News Feed: Consulting constant updates on stressful current events may worsen feelings of stress and anxiety. Try limiting the time spent looking at news media to once or twice a day, and keep electronic devices out of the bedroom.
• Keep Up With Your Hobbies and Interests: Participating in hobbies is associated with better psychological well-being, improved blood pressure and stress hormone levels, and better sleep.
• Unwind Before Bed: Find a relaxing activity such as reading, yoga, or taking a warm bath to include in your nightly routine.
• Use Relaxation Techniques: Relaxation techniques are designed to reduce stress and induce a state of relaxation. Examples include progressive muscle relaxation, meditation and guided imagery, and deep breathing, all of which can be done when you are already in bed.
• Connect with Your Family and Friends: Try not to let stress isolate you from your friends and family. Loved ones represent an important source of social support and can help protect against the mental health effects of stressful life events.
• Practice Mindfulness: Focusing too much on negative thoughts, also called rumination, is associated with depression and anxiety. Ruminating may also make it more likely that stressful life events lead to poor sleep quality. Practicing mindfulness meditation, which involves focusing on the present moment, may help you relax in preparation for sleep.

When to Seek Treatment

For many people, incorporating a few lifestyle changes can help reduce stress and improve sleep. However, anyone with concerns about stress or sleep may benefit from working with a professional. If you experience any of the following symptoms for more than two weeks, it is time to seek professional treatment:

• Persistent trouble sleeping
• Low mood that makes you reluctant to get out of bed
• Changes in appetite or body weight
• Trouble focusing
• Your hobbies and interests no longer bring you joy
• Ongoing feelings of anxiety
• Feeling like you are unable to cope

If you decide to seek treatment, your primary care physician may recommend their own care plan or refer you to a mental health specialist. Some of the most effective treatments available for stress management and sleep improvement include:

• Counseling: Counseling may help manage stress and improve thoughts surrounding sleep. Cognitive behavioral therapy for insomnia (CBT-I) performed under the guidance of a qualified healthcare professional is considered a first-line treatment for insomnia.
• Medication: Many physicians now avoid treating insomnia with sleep medications due to concerns over their side effects and effectiveness. However, in some cases, medication may be appropriate, particularly for those experiencing both insomnia and mental health issues such as anxiety or depression. Always consult a healthcare professional before starting treatment with any sleep aid.
• Support Groups: Peer support groups can help buffer against feelings of loneliness and isolation and offer a forum for conversation, discussion, and shared experiences.

If you feel overwhelmed by stress or are having thoughts about suicide, you should contact the National Suicide Prevention Lifeline. Confidential support is available 24 hours a day, every day of the week. For immediate emergencies, call 911.

• Centers for Disease Control and Prevention: The CDC has a helpful page with tips on how to cope with stress. The site also includes a wealth of resources and social support services for dealing with mental health crises.
• American College of Cardiology: This ACC page is directed towards health care workers but includes a detailed guide for controlled breathing that anyone can use to manage stress.
• Anxiety and Depression Association of America: The ADAA offers a free online tool that allows people experiencing mental health challenges to connect with each other and share experiences and local resources.
• Insight Timer: This free app includes thousands of guided meditations targeting both stress and sleep.

About The Author

Dr. Michael Breus

Clinical Psychologist, Sleep Medicine Expert

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Michael Breus, Ph.D is a Diplomate of the American Board of Sleep Medicine and a Fellow of The American Academy of Sleep Medicine and one of only 168 psychologists to pass the Sleep Medical Specialty Board without going to medical school. He holds a BA in Psychology from Skidmore College, and PhD in Clinical Psychology from The University of Georgia. Dr. Breus has been in private practice as a sleep doctor for nearly 25 years. Dr. Breus is a sought after lecturer and his knowledge is shared daily in major national media worldwide including Today, Dr. Oz, Oprah, and for fourteen years as the sleep expert on WebMD. Dr. Breus is also the bestselling author of The Power of When, The Sleep Doctor’s Diet Plan, Good Night!, and Energize!

• POSITION: Combination Sleeper
• TEMPERATURE: Hot Sleeper
• CHRONOTYPE: Wolf

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