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Too Stressed to Sleep

When worry is bad news for bedtime

woman in bed with insomnia that can't sleep white backgroundStress is common in our fast-paced, highly connected world. Stress is the feeling of being under too much mental or emotional pressure. Pressure turns into stress when you feel unable to cope. Many of life’s demands can cause stress, particularly work, relationships and financial problems.

Stress can affect how you feel, think, behave and how your body works. Common signs of stress include sleeping problems, headaches, muscular aches, digestive problems, difficulty concentrating, depression and irritability.

Why am I up at night?

Up to 70% of the population experience stress or anxiety on a daily basis and report difficulty sleeping as a result. The majority of adults with a stress-induced sleep problem experience it at least once per week, and more than half experience it at least several times a week. Three-quarters of adults whose sleep is affected by stress or anxiety say that their sleep problems have also increased their stress and anxiety.

By far, the commonest manifestation of stress on sleep is insomnia, which is usually transient. However, stressors that do not resolve quickly may continue to produce insomnia. Often, even after the original stressor has resolved, insomnia remains as it has become a conditioned response. Worry about poor sleep often becomes the major stressor perpetuating chronic insomnia.

Insomnia is a persistent and distressing condition related to:

  1. The inability to fall asleep
  2. The inability to stay asleep during the night or difficulty going back to sleep if one wakes in the night
  3. Waking up too early in the morning
  4. Waking up feeling unrefreshed

It is usually accompanied by daytime tiredness, lack of energy, irritability, poor memory and concentration.

Insomnia is classed as chronic if the symptoms last a month or longer. It can be primary – not directly associated with any other health condition, or secondary – a result of an underlying medical condition or drugs or medications, including caffeine or alcohol. Patients should be evaluated by a sleep physician to rule out underlying medical or psychiatric conditions which may require treatment.

How can I go back to sleep?

There are two main approaches for treating poor sleep: pharmacological and behavioural.


Common insomnia prescriptions include benzodiazepines (e.g. Lorazepam and Diazepam), as well as newer drugs such as Zopiclone and Zolpidem. Although effective, they are associated with tolerance, addiction, residual hangover effects and rebound insomnia, and may increase the likelihood of parasomnias (such as sleepwalking) in susceptible patients.

In some studies, melatonin has been shown to be effective, particularly where there has been a disruption to the body’s biological clock or circadian rhythm.

Other commonly used medications include sedating antidepressants (e.g. amitriptyline or mirtazapine) and sedating antipsychotics (e.g. quetiapine or olanzapine). However, side effects include heart rhythm disturbances, dry mouth, difficulty passing urine and confusion, especially in the elderly.


Cognitive behavioural therapy targets the maladaptive behaviours and beliefs that have developed or contributed to the development of insomnia. It is the gold standard in the treatment of insomnia and has been shown to be more effective long-term than pharmacological treatments. Cognitive behavioural therapy consists of several major components, usually implemented in combination.

Sleep hygiene emphasises the environmental and physiological factors, behaviour and habits that promote good sleep. These include:

  1. Maintaining a regular sleep-wake schedule
  2. Avoiding daytime naps
  3. Regular exercise (but not close to bedtime)
  4. Avoidance of stimulants such as caffeine and nicotine
  5. Alcohol avoidance – alcohol actually promotes sleep fragmentation, resulting in frequent awakenings during sleep
  6. Ensuring that the bedroom is cool, quiet, dark and comfortable for sleeping

Stimulus control is a reconditioning treatment which encourages discrimination between the daytime and sleeping environment. Removing stimulants (TV, computers, games, social media) from the bedroom and limiting bed activities to sleeping and intimacy helps to re-establish the link between the bed and sleep. Developing a bedtime routine, such as reading or listening to music before bed, allows you to “wind down” after the day’s hectic activities.

Don’t force yourself to sleep. This frequently backfires and creates more mental and physical stress, keeping you awake. Similarly, “clock watching” or watching the sleepless night go by only leads to more worry and frustration, worsening insomnia. Instead, get up and do something sedentary or boring until you feel sleepy, then return to bed and try again.

Sleep restriction therapy restricts the time in bed, resulting in an element of sleep deprivation, thereby increasing the body’s own physiological drive to sleep. As sleep becomes more consolidated, the length of time in bed is gradually increased in 15- to 30-minute increments.

Relaxation techniques include progressive muscle relaxation, guided imagery, breathing techniques and meditation. These distract the mind and help to reduce physical and mental arousal.

Unlike medications, cognitive behavioural therapy addresses the underlying causes of insomnia rather than just relieving symptoms. But like trying to break a habit, it takes time and effort to work. A combination of sleep medication and behavioural techniques may be required. It is best to speak to your sleep physician to find out the best approach for you.

Dr Lee Yeow Hian is a Consultant Respiratory, Sleep and Intensive Care Physician at Lee Respiratory and Sleep Clinic, Mount Elizabeth Novena Hospital, Singapore.
Posted by ezyhealth on Mar 31 2015. Filed under Health. You can follow any responses to this entry through the RSS 2.0. Both comments and pings are currently closed.

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