Stress and Insomnia

I have a stress-filled job, and I also have periodic bouts of insomnia. Could there be a connection between the two?

In a word, yes. Not all insomnia is due to stress, but people who are under considerable stress can have insomnia. In the case of insomnia related to stress, alleviating the stress should alleviate the insomnia. Stress causes insomnia by making it difficult to fall asleep and to stay asleep, and by affecting the quality of your sleep. Stress causes hyperarousal, which can upset the balance between sleep and wakefulness.

Nevertheless, many people under stress do not have insomnia.

How can I know if my insomnia is the result of stress, or something else?

As with any symptom, an important question to ask is "when did it start?" Does the sleep problem come and go with the occurrence and disappearance of stress or does it persist through all the permutations of one's life? That is, is it situational? Also it is helpful to clarify what one means by stress.

For example, are you frequently anxious whether or not you are under unusual stress? Is it hard for you to "wind down" at the end of the day? Are you frequently infuriated? Or do you feel depressed? If you feel "blue" much of the time, your problem may be a mood disorder, like depression, more than a problem with stress.

What then should I do to help my insomnia?

No matter what the cause of your insomnia, it's important to get on a good behavior program—one that pays attention to periods of relaxation. I suggest three steps:

• First, set your bedtime and your wake-up time according to the number of hours of sleep you are getting currently. For example, if you are sleeping only five hours a night (even though you usually plan to spend eight hours in bed), set your sleep time for that amount. Then gradually increase the amount of time allotted for sleep by 15 minutes or so every few nights. The idea is to "squeeze out" the middle of the nighttime awakening and gradually increase the amount of sleep you will get during the night.
• Spend some time "winding down." A person with insomnia needs a "buffer zone," a period of time to allow the activating processes in the brain to wind down to allow the alerting mechanisms to decrease their activity so that the sleep systems can take over. I suggest that you start winding down two hours before bedtime. Stop all work and end phone calls to family and friends, as often they are activating. Watching television is all right in the evening. However, an hour before bed, I recommend reading or listening to music.
• Finally, focus on conditioning yourself for different sleep behavior. Insomnia is painful for people—it can take control of their lives. When someone suffering from insomnia walks into their bedroom, they often feel anxious, uncomfortable and tense, as they know from their experience that they might spend the night tossing and turning. They need to set up a situation so that they like going to their bedroom. The bedroom should be visually pleasing and very comfortable. One should use the bedroom only for sleep, sex, and changing clothes, pleasant activities, and if awake in the night should leave the bed and bedroom and spend "unpleasant" times awake in another room. "Waking" activities such as working on the computer, talking with one's partner, talking on the phone and watching TV should take place out of the bedroom.

What about over-the-counter medications? Do they help?

Over-the-counter medications, in combination with a good behavior program, can be helpful for a few days; but the problem with OTC medications is that they tend to have limited effectiveness over the long term and can have a high incidence of "hangovers." Many people taking OTC medications still feel tired the next day and attribute it to their insomnia, but it can be a lingering effect of the medication. Be wary of OTC medications— use them only as you would aspirin for a headache, only so much for so long.

At what point should I seek professional help?

It's important to recognize that transient insomnias are very common. A night or two of insomnia may not be much of a problem for most people. But if insomnia persists for days and has an impact on the way you feel during the day, you should think about speaking to your doctor. Most doctors will turn to sleep aids for short-term insomnia. When judiciously used, medications can be very safe and highly effective in combination with the kind of behavioral program I've described. If the problem persists, you might need to turn to find a sleep professional.

What's the most important thing to know about insomnia?

A lot of people suffer from insomnia, and they say to themselves, "I know what this is, but I can't do anything about it." However, consider the toll insomnia takes on your life, the effect it has on your family, your ability to work at a high level, and to socialize with others. The consequences are so enormous that it's important to do something about it. It can be addressed through proper diagnosis and treatment. And if your physician can't help you, seek out an expert in sleep medicine. By all means, don't accept it as a necessary part of your life.

-- Neil B. Kavey, MD, is Director of the Sleep Disorders Center at The New York-Presbyterian Hospital at Columbia Presbyterian Medical Center in New York City. He has been practicing sleep medicine since 1973.

This article originally appeared in the Spring 2001 issue of sleepmatters.

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