According to the American Institute of Stress, 33% of people feel extreme stress, 77% experience stress that affects their physical health, and 48% have trouble sleeping because of stress. World events are just making stress levels worse for almost half of Americans. (1)
Disordered sleeping and lack of sleep affect 50-70 million American adults. Stress is a common factor that contributes to sleep difficulties. Considering the interconnected relationship between sleep and stress (called the "sleep-stress cycle"), it's no wonder Americans are stressed out and sleep deprived.
Neuroadrenal biomarkers can be valuable data points when trying to get to the root of this problem and reverse this vicious cycle. Complementary and alternative medicine therapies help to target imbalances identified in the body's physiologic pathways related to the stress response to help patients press reset on stress and sleep.
What is Stress?
Stress is a physical, mental, or emotional strain or threat that evokes biochemical and physiological responses in the body. There are two components of the biological stress response; the first is that the brain stimulates the sympathetic nervous system (often called the "fight or flight" response), which produces neurotransmitters, like adrenaline, from the adrenal glands. The second part of the stress response activates the hypothalamus-pituitary-adrenal (HPA) axis, a hormonal cascade ending in cortisol release from the adrenal glands. (1)
Not all types of stress are harmful, and some stressors can be beneficial, as explained by the phenomenon of hormesis - in which an external stimulus results in stimulating and beneficial outcomes. However, chronic stress and hyperarousal, when unaddressed, can lead to burnout, decreased productivity, and a detrimental impact on the mind and body. (1)
Stress makes relaxation difficult due to the emotions it elicits, like anxiety and irritability. Stress also can manifest in the body physically, inducing symptoms like headaches and body pains. Chronic stress can exacerbate preexisting chronic medical conditions, especially mental health conditions like depression. (4)
What is the Sleep-Stress Cycle?
The sleep-stress cycle is the notion that sleep and stress are interrelated and affect each other. This bidirectional relationship can be frustrating when high stress levels contribute to trouble sleeping, and poor quality and lack of sleep worsen stress maladaptation. (5)
How Does Stress Affect Sleep?
Chronic stress causes dysregulation of the circadian rhythm, also known as the sleep-wake cycle. When people experience stress, they are more likely to have trouble falling and staying asleep at night. In fact, 43% of adults report that stress causes them to lie awake at night. Stress can reduce deep sleep and rapid eye movement (REM) sleep, both critical for maintaining mental and physical health. (5-7)
Cortisol and melatonin are two hormones important in regulating the sleep-wake cycle. These two hormones have an inverse relationship: when cortisol is high, melatonin is low, and vice versa. Cortisol is our "get-up-and-go" hormone, whereas melatonin has the opposite effect. In a healthy state, cortisol should be highest in the morning and gradually decrease throughout the day to be lowest at night. In contrast, melatonin secretion begins in the evening, peaks between 2-4 a.m., and then decreases, so it is lowest in the morning. This diurnal hormone variation signals the body when to wake and sleep, setting the circadian rhythm. In times of chronic stress and HPA axis activation, cortisol levels become dysregulated, offsetting the balance of the circadian rhythm and negatively affecting the ability to sleep soundly. (8)
Physical manifestations of sleep can also disrupt sleep quality. Uncomfortable feelings of increased muscle tension, rapid heart rate, shortness of breath, digestive symptoms, and ruminating thoughts interfere with the relaxation needed for peaceful sleep. (2)
How Does Lack of Sleep Affect Stress Levels?
Poor sleep influences cortisol levels and systemic inflammation. Sleep inhibits the HPA axis, but insufficient sleep is associated with increased cortisol secretion and hyperarousal of the nervous system.
The Stress in America survey conducted by the American Psychological Association concluded that 21% of adults feel more stressed after not getting enough sleep. While it is recommended for adults to get 7-9 hours of sleep nightly, American adults report sleeping an average of only 6.7 hours a night. Additionally, adults who sleep less than eight hours nightly report higher stress levels than those who sleep at least eight hours. (5)
Common Sleep Disorders That Can Affect Quality of Sleep
Sleep disorders can have a significant impact on the quality of sleep. Here are some examples:
Insomnia is a sleep disorder characterized by the inability to fall asleep quickly or stay asleep. It is estimated that up to two-thirds of adults are afflicted by insomnia. Insomnia is classified as acute (having symptoms for less than three months) or chronic (persistent symptoms at least three times weekly for at least three months). (2)
Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder characterized by the collapse of the upper airways during sleep, resulting in heavy snoring, choking, and cessation of breathing. It commonly presents with daytime sleepiness. (2, 3)
Restless Legs Syndrome (RLS)
RLS is a neurological condition characterized by a "creeping" sensation, aches, and pains throughout the legs that are typically alleviated with movement and stretching. RLS symptoms usually worsen at night, interfering with sleep initiation and maintenance.
Narcolepsy is a chronic neurological disorder that disrupts healthy sleep-wake cycles, resulting in excessive daytime sleepiness and interrupted sleep during the night. Sudden muscle weakness (cataplexy) is a hallmark symptom of narcolepsy, and other common symptoms include hallucinations and sleep paralysis.
Functional Medicine Labs to Test for Root Cause of the Sleep-Stress Cycle
Functional medicine providers use specialty labs to help personalize treatment plans. Below are some of the most common specialty labs ran for sleep-stress cycle dysfunction.
Hypothalamic-Pituitary-Adrenal Axis Testing
Salivary cortisol tests measure cortisol multiple times to map its levels throughout the day. Salivary cortisol is a marker of active free cortisol that is available for use by the body. Test reports map out secretion patterns, making it easy to diagnose HPA imbalances resulting from and contributing to stress.
Dehydroepiandrosterone (DHEA) is a neurosteroid produced by the adrenal gland with antioxidant and anti-inflammatory properties, offsetting cortisol's effects in the body. Chronic stress can result in low DHEA levels, and a low DHEA:cortisol ratio indicates HPA dysfunction. It is often measured on a salivary cortisol panel but can also be measured in the blood.
The cortisol awakening response (CAR) is a distinct component of the circadian cortisol cycle, representing the natural rise of cortisol in the early morning. Chronic HPA axis stimulation induces changes in the CAR, so a salivary measurement can help identify the impact stress has on the biological clock and cortisol secretion.
A melatonin profile measures salivary melatonin at different times during the day to assess for variations in the healthy diurnal pattern that supports a healthy sleep-wake cycle.
Chronic stress and sleep disorders are linked to imbalances in neurotransmitters. A neurotransmitter test can aid in assessing nervous system activation during the biological stress response, and imbalances can provide insight into the mental, emotional, and physical symptoms caused by stress.
Because it can be beneficial to measure the above biomarkers in conjunction with one another to evaluate the physiologic repercussions of the sleep-stress cycle holistically, a combination panel may be a preferred testing option.
The HPA Profile is a salivary and urinary test that measures neurotransmitters, cortisol, and DHEA. It is an ideal panel for patients experiencing symptoms related to stress.
The Rhythm Plus + CAR test is designed for premenopausal and perimenopausal women. This panel includes the Adrenocortex Stress Profile (measures cortisol and DHEA), CAR, a melatonin profile, and a 28-day comprehensive assessment of sex hormones.
The Sleep and Stress Panel measures salivary cortisol and melatonin levels throughout the day to easily compare the two hormones and evaluate the sleep-wake cycle.
Nutrition for the Sleep-Stress Cycle
Chronic stress increases the body's metabolic demands and its elimination of certain micronutrients, putting you at risk for nutritional deficiencies. A balanced diet of fruits, vegetables, whole grains, healthy fats, and lean meats can provide the body with the nutrients it needs to support healthy stress responses, maintain energy levels throughout the day, and induce deep sleep. (9, 10)
Avoid caffeine, which activates the biological stress response and increases the adrenal output of cortisol and adrenaline. Furthermore, caffeine's stimulant effects can last hours in the body, disrupting the ability to sleep at night (10).
Supplements & Herbs for the Sleep-Stress Cycle
Ashwagandha is an adaptogenic herb that acts in the body to lower cortisol levels, reduce anxiety and inflammation, and support sleep. Integrative providers often recommend adaptogens to help patients to regulate and balance stress responses. Data supports the use of ashwagandha in improving sleep quality and reducing chronic stress.
L-Theanine is an amino acid naturally found in green tea that has been shown to reduce symptoms of acute stress and anxiety.
Aromatherapy uses essential oils to stimulate parts of the brain to influence emotions and is commonly used to ease stress and anxiety, boost feelings of relaxation, and improve sleep quality. Clary sage, bergamot, and lavender oils have evidence supporting their use to lower cortisol levels (8).
Supplemental melatonin can be used safely short term to foster evening melatonin levels and induce sleep in patients with sleep disorders. A 2013 meta-analysis concluded that melatonin helps people with insomnia fall asleep faster, sleep longer, and have better sleep quality.
Gamma-aminobutyric acid (GABA) is a calming neurotransmitter that regulates mood, emotions, and sleep cycles. Low levels of GABA can result in anxiety, depression, irritability, restlessness, and poor sleep. Ensuring adequate B vitamin and magnesium intake, partaking in gentle yoga, and abstaining from alcohol can naturally support optimal GABA levels. Supplemental GABA has also been shown to alleviate mental stress.
Complementary and Alternative Medicine for the Sleep-Stress Cycle
Light is a primary regulator of circadian rhythm and can influence cortisol and melatonin levels. Exposure to daylight in the morning and early afternoon supports healthy diurnal variation in cortisol and melatonin and helps to induce sleep at night. Additionally, the blue light emitted through electronic screens can impair the natural nighttime secretion of melatonin and interfere with sleep. Wearing blue light-blocking glasses in the evening and turning off screens at least 30 minutes before bed can positively affect sleep.
Creating a relaxation response using relaxation techniques can counteract the adverse effects of stress and promote good sleep. Many alternative methods have been shown to promote a healthy relaxation response.
Yoga for the Sleep-Stress Cycle
Many types of yoga, including Hatha and Yin, have beneficial effects on reducing stress levels and symptoms.
Biofeedback for the Sleep-Stress Cycle
Heart rate variability (HRV) measures the variation in time between each heartbeat and is used as a marker of resilience to stress. HRV biofeedback has been studied as an effective method to reduce stress and anxiety.
Breathing Exercises for the Sleep-Stress Cycle
Slow-paced breathwork stimulates the vagus nerve to emphasize the "rest and digest" functions of the parasympathetic division of the nervous system. Vagal nerve stimulation improves stress, anxiety, and mental health.
Mindfulness for the Sleep-Stress Cycle
If you are stressed out and can't sleep or feel more stressed after a night of poor sleep, you might be a victim of the sleep-stress cycle. Given this "chicken or egg" dilemma, knowing where to start when unraveling this vicious cycle to reset stress and sleep can be tricky. Specialty testing can pinpoint biochemical imbalances contributing to the perceived mental and physical symptoms of stress and sleep disruptions so that targeted therapies can be implemented to foster balance in the HPA axis and nervous system.
Lab Tests in This Article
1. Boyd, D. (2022, March 30). Daily Life - The American Institute of Stress. The American Institute of Stress. https://www.stress.org/daily-life
2. Fry, A. (2023, February 9). Stress and Insomnia. Sleep Foundation. https://www.sleepfoundation.org/insomnia/stress-and-insomnia
3. Kline, L. (2023, January 13). Clinical presentation and diagnosis of obstructive sleep apnea in adults. UpToDate. https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-obstructive-sleep-apnea-in-adults
4. Stress. (2022, June 17). https://www.who.int/news-room/questions-and-answers/item/stress#
5. Stress and sleep. (2013, January 1). https://www.apa.org. https://www.apa.org/news/press/releases/stress/2013/sleep
6. Kim, E., & Dimsdale, J.E. (2007). The Effect of Psychosocial Stress on Sleep: A Review of Polysomnographic Evidence. Behavioral Sleep Medicine, 5(4), 256–278. https://doi.org/10.1080/15402000701557383
7. Pacheco, D. (2023, March 3). Deep Sleep: How Much Do You Need? Sleep Foundation. https://www.sleepfoundation.org/stages-of-sleep/deep-sleep
8. LoBisco, S. (2022, December 19). How to Balance Melatonin and Cortisol Levels. Rupa Health. https://www.rupahealth.com/post/how-to-balance-melatonin-and-cortisol-naturally-for-better-health
9. Stress and Health. (2023, February 2). The Nutrition Source. https://www.hsph.harvard.edu/nutritionsource/stress-and-health/
10. Sleep Foundation. (2022, February 10). Healthy Sleep Habits. https://www.sleepfoundation.org/sleep-habits