Sleep is essential for humans to function, while chronic stress can be the enemy of good health. Steve Titmarsh explains…
Insomnia and chronic stress afflict many people in the modern world so methods to combat and prevent them are important.1,2
Insomnia - in a broad sense of the term - is surprisingly common. Around 1 in 3 adults in Western countries report sleep problems at least once a week, and in 6–15 per cent of cases there is significant impact on daytime functioning. The problem can be long-term, lasting at least a year, in about three-quarters of patients.3
Medically, insomnia can be defined as difficulty in getting to sleep, difficulty maintaining sleep, early wakening, or non-restorative sleep. This occurs despite adequate opportunity for sleep and leads to poor daytime functioning. It can be short-term, lasting for less than three months, or chronic where it happens at least three nights a week for three or more months. Insomnia affects women more than men and is more common in older people.3
Insomnia is associated with activation of the hypothalamic-pituitary-adrenal (HPA) axis, with increases in adrenocorticotrophin (ACTH) and cortisol.3 Stress responses also involve changes in activity in the HPA axis.2
There is no formal medical definition of stress. The Health and Safety Executive (HSE) describes it as: “The adverse reaction people have to excessive pressure or other types of demands placed upon them. It arises when they perceive that they are unable to cope with those demands.”
The HSE adds that: “Stress arises when the demands upon us outweigh the resources we have to deal with those demands.”4,5
Physiological origins of stress
The HPA axis, which consists of the hypothalamus, the pituitary gland and the adrenal glands, stimulates the sympathetic nervous system via hormonal signals. With continued stimulation, the hypothalamus releases corticotropin-releasing hormone (CRH), which triggers the release of adrenocorticotropic hormone (ACTH) from the pituitary gland.
In turn, ACTH prompts the adrenal glands to release cortisol.6 So although short term stress may be beneficial – such as for avoiding danger – chronic low-level stress can contribute to the health problems. Common signs and symptoms of stress include:7,8
• constant worry or anxiety • feeling overwhelmed
• difficulty concentrating • mood swings or changes in mood
• irritability or short temper • difficulty relaxing
• depression • low self-esteem
• eating more or less than usual • sleeping habit changes
• using alcohol, tobacco or illegal drugs to relax
• aches and pains, particularly muscle tension
• diarrhoea and constipation • nausea or dizziness
• loss of sex drive.
Relaxation techniques may help relieve stress. For example, deep breathing techniques, or muscular tensing and stretching.7
Developing resilience can help reduce the impact of stress and help people adapt to future challenges. Making lifestyle changes can help build resilience, for example:5
· Practise being straightforward and assertive
· Develop interests and hobbies
· Make time for friends
· Have enough sleep
· Exercise and eat healthily
· Reward personal achievements
· Have a change of scenery
· Resolve conflicts
· Forgive yourself.
Determining whether someone has sleep problems can be done by simply asking them: are they having difficulty getting to sleep and/ or staying asleep? Is this occurring most nights? Is this persistent and affecting how they feel during the day?
Patient sleep diaries are also useful. It is important to excluded physical, neurological and psychiatric causes that may need treatment. For example, insomnia can be associated with mental illness.2
Short-term insomnia can usually be resolved by identifying the cause and dealing with it. Chronic insomnia tends to be associated with older age, and where symptoms are more severe when the insomnia starts.5 It can be triggered by a specific problem or a change in sleep pattern due to the birth of a child or shift work, for example.3
People with short-term insomnia should be advised about sleep hygiene (see panel). It is also important to ensure that any other illnesses associated with poor sleep such as depression or anxiety are properly managed. Cognitive behavioural therapy for insomnia is also an option.9
If sleep hygiene alone does not work a short course – 3 to 7 days – of non-benzodiazepine hypnotic medication might be considered. NICE advises that hypnotics should be prescribed for short-term use (up to two weeks) only when non-drug measures have failed and insomnia is severe, disabling or causing extreme distress.9
NICE notes that the risks associated with hypnotics, such as falls, cognitive impairment, dependence and withdrawal symptoms, are well recognised. Recent data also suggest that risks such as falls are associated with melatonin.10
OTC preparations for insomnia should not be recommended, according to NICE Clinical Knowledge Summaries.9However, the NHS website acknowledges the availability of sleeping aids OTC containing valerian, lavender, melatonin or antihistamine, and says they should not be taken for more than one or two weeks. It warns that they may have side effects, including drowsiness.11
People who have had insomnia for more than three months may need a specialist referral for further investigation. Sleep hygiene measures or cognitive behavioral therapy may help but medicines should be avoided except in some circumstances where there are severe symptoms when a short course of a hypnotic might be added, and in some people over the age of 55 years melatonin might be prescribed for a maximum of 13 weeks.9
The sleep environment
· Comfortable: not too hot or too cold or too noisy or bright
· Avoid devices emitting blue light such as smartphones two hours before bedtime. Blue light suppresses melatonin production
· Use the bedroom for sleep and intimacy only.
· Go to bed when sleepy; not too early
· Try to wake and get up at the same every day, including after a poor night’s sleep
· Do not take daytime naps
· Relaxation exercises in the early evening may help reduce hyper-arousal
· Visual imagery in bed may help racing thoughts
· Avoid caffeine after midday
· Avoid nicotine, alcohol and large meals within two hours of bedtime
· Avoid exercise within four hours of bedtime
Mental Health Foundation. How to sleep better (www.mentalhealth.org.uk/publications/how-sleep-better)
Royal College of General Practitioners. Top tips: insomnia in adults (www.rcgp.org.uk/clinical-and-research/resources/toolkits/mental-health-toolkit/top-tips-insomnia-in-adults.aspx)
The Sleep Charity, which incorporates The Sleep Council, provides advice and support to promote better sleep (https://thesleepcharity.org.uk)
NHS.UK Insomnia (www.nhs.uk/conditions/insomnia)
Drug treatment of insomnia: www.bap.org.uk/pdfs/BAP_Guidelines-Sleep.pdf
1. Sleep Foundation. Stress and insomnia (www.sleepfoundation.org/insomnia/stress-and-insomnia; accessed 4 January 2022).
2. Han KS, Kim L, Shim I. Stress and sleep disorder. Exp Neurobiol 2012;21(4):141–50.
3. Wilson S, Anderson K, Baldwin D, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update. J Psychopharmacol 2019;33:923–47.
4. Royal College of Nursing (RCN). Stress and you: a short guide to coping with pressure and stress. London: RCN, 2015.
5. MIND. How can I be more resilient? (www.mind.org.uk/information-support/types-of-mental-health-problems/stress/developing-resilience; accessed 4 January 2022).
6. Harvard Health Publishing. Harvard Medical School. Understanding the stress response (www.health.harvard.edu/staying-healthy/understanding-the-stress-response; accessed 4 January 2022).
7. Mental Health Foundation. How to manage and reduce stress (www.mentalhealth.org.uk/publications/how-manage-and-reduce-stress; accessed 4 January 2022).
8. NHS.UK Stress (www.nhs.uk/mental-health/feelings-symptoms-behaviours/feelings-and-symptoms/stress; accessed 4 January 2022).
9. Clinical Knowledge Summaries. Insomnia (https://cks.nice.org.uk/topics/insomnia; accessed 6 January 2022).
10. National Institute for Health and Care Excellence (NICE). Hypnotics. Key therapeutic topic [KTT6] (www.nice.org.uk/advice/ktt6/chapter/Key-points; accessed 6 January 2022).
11. NHS.UK. Insomnia (www.nhs.uk/conditions/insomnia; accessed 6 January 2022).
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