Tips for Stressed-Out Caregivers Seeking Better Sleep

Occasionally I get emails from people with take-charge, type A personalities wondering what to do about insomnia. Full of self-reliance, they’ve often scoured the internet for remedies—and tried every one—or amassed a mountain of books about sleep—and read them all—to little avail. Can I suggest anything that might help?

Here is Geri’s story (abbreviated to save space) and my response.

Insomnia can be relieved by focusing on stress reduction and self-careOccasionally I get emails from people with take-charge, type A personalities wondering what to do about insomnia. Full of self-reliance, they’ve often scoured the internet for remedies—and tried every one—or amassed a mountain of books about sleep—and read them all—to little avail. Can I suggest anything that might help?

Here is Geri’s story (abbreviated to save space) and my response.

A Caregiver’s Hectic Life

I have had insomnia since 2005. I have four children (13, 10, 9 and 7) and at time of onset only had one. Triggered by changing jobs and trying to get pregnant—so stressful! I am a community mental health nurse. I have a caseload of 22 adults with psychosis and am their primary support. . . . [At night] it can take 2 hours for me to fall asleep and then I usually wake between 12 and 2 a.m. I do not go back to sleep. . . . I am naturally an over thinker, I do stress easily and worry a lot. . . . I’ve never been a great sleeper but yes I used to sleep. We are struggling financially so not working is not an option. . . . I have a library of books on sleep, have spent hundreds of pounds on various remedies and treatments—but alas nothing really seems to help. Can you suggest anything?

Geri had a lot on her plate. She was on the go all the time, caring for patients during the workday and children at night. Her busy schedule didn’t leave much time for self-care.

She knew what she needed: fewer responsibilities. If she won the lottery, she said, she’d resign from nursing, fix up her house, and be the mother and relaxed partner she’d like to be. But that was not in the cards.

Adding Things In, Cutting Things Out

Despite her time constraints, Geri was resourceful in looking for insomnia remedies. She’d also established some habits conducive to sound sleep: eating healthy foods, getting plenty of exercise by cycling to and from work and her patients’ homes, and practicing mindfulness.

But she’d also tried a raft of insomnia remedies that didn’t seem to help, from herbs and homeopathic insomnia cures to acupuncture and CDs with “odd sleep-inducing sounds.” When Geri wrote to me, she was planning to ramp up her efforts to improve her sleep by:

  • Adding high-intensity interval training to the cycling she did everyday (though it was a struggle to find the energy for this activity)
  • Cutting out alcohol completely (which, in times of desperation, she used to get to sleep)
  • Cutting out processed sugar, including the “crap biscuits” (cookies) she was prone to eat when super tired

What did I think?

Regimentation, Stress and Sleep

My immediate reaction on reading Geri’s story was that I could never do half of what she does and expect to sleep consistently well. With so many responsibilities I’d be popping Valiums every day!

Seriously, though, Geri’s sleep problem may have been related to chronic stress and the double duty she was doing as caregiver for her patients and her children (i.e., caregiver stress). Even so, her inclination was not to find ways to make her responsibilities more manageable. It was to do still more, adding high-intensity interval training to an already busy schedule and restricting an already healthy diet still further.

I wondered if the restrictive regimen she was about to impose upon herself would sooner or later become yet another source of stress. It’s true that exercise is beneficial to sleep. But nowhere has it been suggested that a person should have to cycle to and from work and do high-intensity interval training to get better sleep.

Dietary Choices and Sleep

It’s also true that what we eat can affect our sleep. But having a cookie now and then is probably not going to make a difference. There’s a lot of information now suggesting that overindulgence in simple carbohydrates is harmful to health. We shouldn’t routinely have Hostess cupcakes washed down with Pepsi for lunch. But cut out sugar completely? I follow the literature on insomnia and sleep pretty closely, and not one study I’ve seen has shown that cutting sugar out altogether from our diets will improve sleep.

Likewise, it’s smart to avoid using alcohol for sleep. But a glass of wine at happy hour is probably not going to have much impact on the night at all. It sounds punitive for Geri to try to regiment her life still more than it already is.

Reduce Stress With Better Self-Care

It could be that Geri would benefit from consulting a sleep doctor or a sleep therapist and that cognitive behavioral therapy for insomnia, administered by a trained professional, might help. A sleep study might uncover an underlying sleep disorder (or show she was getting more sleep than she thought).

But I think Geri’s sleep would improve if she were to reduce her stress by engaging in more nurturing self-care. She’s got a head start on some of the ways to do this but other readers may not:

  • Take half an hour a day for yourself and do something purely for pleasure (gardening, reading a novel, playing the piano)
  • Learn and use stress reduction techniques such as meditation, yoga, or Tai Chi.
  • Stay current with your own healthcare needs.
  • Eat regular, healthy meals.
  • Exercise daily.
  • Take time off when you can.
  • Maintain ties with friends and supportive family members, and when possible seek and accept their support.
  • Seek counseling when you need it or reach out to friends

If you’re a full-time caregiver, what’s the best way you’ve found to take care of yourself?

Tips for Relieving Stress and Improving Sleep

Do stressful situations throw your sleep off track? You’d probably score high in sleep reactivity, a stable trait associated with insomnia. If a rough day at work kept you tossing and turning last night, then similarly charged situations—arguing with your spouse, getting bad news, preparing to speak in public—may disrupt your sleep now and then.

But what if the stress is chronic? Then it’s time to deal with it head on. Here are four ways to reduce stress and improve sleep.

Stress-related Insomnia can be alleviated with social supportDo stressful situations throw your sleep off track? You’d probably score high in sleep reactivity, a stable trait associated with insomnia. If a rough day at work kept you tossing and turning last night, then similarly charged situations—arguing with your spouse, getting bad news, preparing to speak in public—may disrupt your sleep now and then.

But what if the stress is chronic? Then it’s time to deal with it head on. Here are four ways to reduce stress and improve sleep.

Have a Physical Outlet for Stress

Persistent activation of the stress-response system results in higher-than-normal levels of cortisol and other stress hormones, all harmful to long-term health. Not only does this increase your susceptibility to chronic insomnia, but it also suppresses your immune system and elevates your risk of hypertension, heart disease, and depression. It interferes with learning and memory as well.

Exercise—jogging, swimming, bicycling, playing tennis—protects against development of stress-related disease. Immediately following a workout there’s a decrease in muscle tension and a release of body heat, which can hasten sleep onset and enhance sleep quality. Exercise can also help to elevate mood. Long-term, regular exercise tends to lower the resting heart rate, making it easier to relax.

But to maximize stress relief, choose a form of exercise you enjoy (or at least find tolerable). Regularity in the timing of workouts, like regularity in the timing of meals, is also conducive to regular sleep. Continuing practice of yoga and meditation can yield similar results.

Reach Out to Friends

Feeling overextended and stressed out can be isolating. Your instinct may be to cut people and relationships out of your life as you move full speed ahead on whatever you need to accomplish.

But having an active social support system is another key way to reduce chronic stress. Research suggests that regardless of who’s doing the talking and who’s doing the listening, interactions with friends and supportive family members help cut down on chronic stress. Participating in group activities can also help with stress relief.

Increase Your Sense of Control When Possible

Some situations are beyond control—diseases that have no cure, job losses due to economic factors, deaths that cannot be prevented. Trying to take control of these situations will likely send your stress off the charts.

But there are situations where exerting more control affords stress relief. For instance, if you’ve got too much on your plate, separate tasks into “musts” and “shoulds” and prioritize them accordingly. To nonessential tasks just say no.

And say no when someone else tries to foist on you a responsibility you cannot fit in. You’ve watched the grandkids for the past three days—now it’s someone else’s turn.

Yes, browsing the internet for the latest political news can be invigorating. But if it tends to work you up too much, vow to tear yourself away from the iPad by 8 p.m.

Increase Predictability

No one likes monotony. Yet a degree of predictability in life tends to lower stress. Says neuroendocrinologist Robert Sapolsky, “When it comes to what makes for psychological stress, a lack of predictability and control are at the top of the list of things you want to avoid.”

If your boss is liable to throw projects your way at any time, including 3 p.m. on Friday, muster up some negotiating skills and request advance notice. If late night phone calls tend to stress you out, ask friends and family to refrain from calling after 9 p.m. If you’re having trouble making ends meet, work up a monthly budget.

The more predictable life is, the better able you will be to plan coping strategies, which will make for better stress resilience and better sleep.

What activity or strategy do you find is most helpful in lowering stress?

Prebiotics Improve Stress Resilience and Sleep

Is stress the driver of your insomnia? Eating more high-fiber foods—sometimes called prebiotics (different from probiotics)—may help both your stomach and your sleep.

In a new study on rats conducted at the University of Colorado, a high-fiber diet promoted the growth of healthy gut bacteria, increased resilience to stress, and made sleep more robust following a stressful event. Here are the take-aways and what the study suggests about human sleep.

Insomnia sufferers should eat high-fiber foods for stress protection and better sleepIs stress the driver of your insomnia? Eating more high fiber foods—sometimes called prebiotics (different from probiotics)—may help both your stomach and your sleep.

In a new study on rats conducted at the University of Colorado, a high fiber diet promoted the growth of healthy gut bacteria, increased resilience to stress, and made sleep more robust following a stressful event. Here are the take-aways and what the study suggests about human sleep.

Stress, Sleep, the Gut, and Probiotics

Most of us sleep better when life is moving along on an even keel. It’s when we have to cope with stressors—a divorce, a bullying boss, sustained combat—that insomnia tends to occur. Chronic stress may eventually lead to chronic insomnia.

Likewise, stress has a harmful impact on the gut. A healthy gut has diverse beneficial bacteria spread evenly throughout the gastrointestinal tract. Stress makes the bacterial community less diverse and less evenly distributed.

One approach to reestablishing a healthy community of gut bacteria is to use a probiotic such as yogurt containing live bacteria, soft cheeses, or a probiotic supplement. Probiotics help repopulate the gut with beneficial bacteria. They’ve also been shown in rodents and humans to reduce the effects of stress on both the body and the brain.

A Prebiotic Diet Has Beneficial Effects

Prebiotics are non-digestible fibers found in certain foods that promote the growth of beneficial gut bacteria such as those found in yogurt and probiotic supplements. The researchers at University of Colorado wondered if feeding young rats a diet rich in prebiotics would increase beneficial gut bacteria and reduce the effects of stress, including its effects on sleep.

So they conducted a controlled experiment using 52 rats. One group was fed a control diet and the other was fed a prebiotic diet. After several weeks, half of the rats in each group were administered a series of tail shocks. The lead author of the study has described these shocks as “the equivalent of a single intense acute stressful episode for humans, such as a car accident of the death of a loved one.”

From analyses of the rats’ fecal material, body functions, and sleep before and after the tail shocks, the authors concluded that the prebiotic diet:

  • Increased stress-protective bacteria in the rats’ gastrointestinal tracts
  • Reduced measurable symptoms of stress
  • Cut down on stress-related wake-ups during recovery sleep
  • Increased beneficial REM sleep during recovery sleep

Overall, the prebiotic diet made the rats more resilient to stress and their sleep more robust.

A High Fiber Diet for Humans?

Would a diet high in prebiotics be similarly protective of the human gastrointestinal tract and human sleep? That, say the researchers, is what they’re going to study next.

For now, given prior clinical research and the fact that there are no known downsides to consuming prebiotic foods, it’s probably a good idea to incorporate more high fiber foods into your diet—especially if you’re prone to stress related insomnia.

Prebiotic Foods

Here are several foods high in prebiotics. You get more mileage from plant fibers when fruits and vegetables are eaten raw, but a light steaming may not do much to diminish their effectiveness.

  • asparagus
  • leeks
  • garlic
  • onions
  • dandelion greens
  • apples
  • bananas
  • jicama
  • Jerusalem artichoke
  • wheat bran
  • bread made of wheat flour
  • barley
  • oats
  • seaweed
  • flaxseeds
  • legumes

Is Low BDNF a Marker of Insomnia?

We’re often told there’s no objective test of insomnia.

But now a research group in Switzerland is claiming they’ve found an objective marker of insomnia: brain-derived neurotrophic factor, or BDNF.

BDNF levels may distinguish insomniacs from normal sleepersWe’re often told there’s no objective test of insomnia. Brain waves aren’t very revealing when it comes to distinguishing insomniacs from normal sleepers. Tests of heart rate variability and metabolic rate have shown slight average differences between groups of people with and without insomnia, but they would not distinguish an individual insomniac from a normal sleeper.

Now a research group in Switzerland is claiming they’ve found an objective marker of insomnia: brain-derived neurotrophic factor, or BDNF.

What Is BDNF?

BDNF is a protein that promotes the survival of nerve cells and the growth of new neurons in the brain and spinal cord. It facilitates communication between neurons, which is important for learning and memory. In addition, BDNF is active in areas of the brain that control appetite and—importantly for this blog post—sleep.

BDNF, Stress, and Mood Disorders

But let’s forget about sleep momentarily and consider the impact of stress and mood disorders (two factors known to have a relationship to sleep) on BDNF levels. Acute stress—meaning stress that is relatively intense and short lasting—leads to an increase in BDNF levels. This increase in BDNF appears to play a part in helping us respond to a stressor, whether internal or from without. Our bodies fight off an infection. We escape from an attacker. BDNF levels return to normal.

But chronic stress (think of chronic inflammation or repeated sexual assaults) tends to decrease BDNF levels. In turn, low levels of BDNF, combined with predisposing and other precipitating factors, increase people’s susceptibility to mood disorders such as major depressive disorder. The neurotrophic hypothesis of depression holds that stress-related mood disorders occur due to a stress-induced decrease in BDNF expression.

Sleep and BDNF

It’s axiomatic now that stress has a relationship to sleep, negatively impacting sleep quality. In turn, poor sleep makes us less resilient to stress. Depression, too, has a close relationship to sleep: sometimes depression gives rise to insomnia and in other cases insomnia leads to depression. But until recently, there was little research on the impact of sleep and stress-related insomnia on BDNF levels.

So the Swiss researchers tackled the problem, assessing levels of BDNF in the blood serum of adults with and without insomnia. A total of 50 participants were screened for insomnia and divided into insomniacs (26) and normal sleepers (24). Here are the key findings:

  • Participants currently suffering from insomnia symptoms had significantly lower serum BDNF levels than the normal sleepers.
  • BDNF levels were significantly correlated with insomnia severity. The greater the insomnia severity, the lower the level of BDNF.

BDNF, Tiredness, and Fatigue

The same team examined the BDNF levels in 12 men who had recovered from occupational burnout. The investigators found that BDNF levels were significantly lower in the men reporting tiredness and fatigue (daytime symptoms associated with insomnia) than in men who did not report these symptoms.

Based on their results, the researchers have come up with a hypothesis. They suggest that chronic stress deregulates the body’s stress system, leading in the long term to insomnia and decreased BDNF levels. Thus low levels of BDNF may be an objective marker of insomnia. They also might account at least in part for the tight relationship between insomnia and depression.

Acute Sleep Deprivation Increases BDNF

There’s some good news in all of this. Remember that while chronic stress lowers BDNF levels, acute stress increases levels of BDNF.

Many studies have shown that acute sleep loss—loss of an entire night’s sleep, for example—leads to a rapid increase of BDNF in the brain. Even partial sleep deprivation, an acute stressor for the brain, seems to work this way. And increased brain BDNF is associated with improved sleep.

If this sounds like talk about sleep restriction, it should. In fact, the sleep investigator who sent the article on which this post is based made the claim outright, saying, “This is why sleep restriction works.”

Find more information about sleep restriction in my book, The Savvy Insomniac, and by clicking Blog at the top of this page. Type “sleep restriction” into the site search box and graze away.

Insomniacs: Are We Dreaming About Sleeplessness?

Rapid eye movement sleep (REM sleep) is when most dreams occur. Episodes of REM sleep also help defuse negative emotions and improve the learning of motor skills.

Until recently, insomnia wasn’t thought to be a problem of REM sleep. Insomnia, the thinking went, was caused mainly by phenomena occurring—or failing to occur—during quiet, or non-REM, sleep: insufficient deep sleep, for example, or wake-like activity occurring in other stages of non-REM sleep, resulting in insufficient or poor sleep.

In the past few years, though, REM sleep has become a suspect in the quest to identify what causes people to wake up frequently in the middle of the night and too early in the morning. (This type of insomnia is called sleep maintenance insomnia). Here’s more about this intriguing proposition.

Insomnia sufferers may be remembering dreams of sleeplessness rather than lying awake for hoursRapid eye movement sleep (REM sleep) is when most dreams occur. Episodes of REM sleep also help defuse negative emotions and improve the learning of motor skills.

Until recently, insomnia wasn’t thought to be a problem of REM sleep. Insomnia, the thinking went, was caused mainly by phenomena occurring—or failing to occur—during quiet, or non-REM, sleep: insufficient deep sleep, for example, or wake-like activity occurring in other stages of non-REM sleep, resulting in insufficient or poor sleep.

But in the past few years, REM sleep has become a suspect in the quest to identify what causes people to wake up frequently in the middle of the night and too early in the morning. (This type of insomnia is called sleep maintenance insomnia). Here’s more about this intriguing proposition.

Do Insomniacs Really Underestimate Sleep Time?

It’s said that insomniacs tend to underestimate the amount of sleep they get. Polysomnography (PSG), the test conducted in the sleep lab, often shows that insomnia sufferers are sleeping more than they think.

Investigators now agree that PSG, as conducted and scored in standard fashion, is too crude a measure to capture what’s going on in disturbed sleep. Finer measures are needed. One such measure involves counting the number of arousals and micro-arousals—brief awakenings—during sleep.

In a seminal study published in 2008, a team of German scientists used PSG, sleep time estimates of study participants, and micro-arousal analysis to ascertain what the differences were between insomniacs and good sleepers. The results showed that compared with good sleepers, insomniacs

  • Got less non-REM and REM sleep overall
  • Experienced more micro-arousals during both non-REM and REM sleep, but the number of micro-arousals during REM sleep was more pronounced: about 2 to 3 times larger than the number experienced by good sleepers. Further, the more REM sleep insomniacs got, the greater was the mismatch between their sleep time as recorded by PSG and the sleep time reported by the insomniacs themselves.

These results suggest that (1) it may be disturbances that occur during REM sleep, more so than during non-REM sleep, that account for the discrepancy between PSG-measured sleep and insomniacs’ perception of their sleep, and (2) disturbed REM sleep may be the main problem for people with sleep maintenance insomnia.

How Disturbed REM Sleep Might Develop

Not much brain activity occurs during non-REM sleep. But REM sleep is marked by a mix of arousal in some parts of the brain and quiescence in other parts. The same group of scientists in a 2012 paper describe REM sleep as “a highly aroused ‘paradoxical’ sleep state requiring a delicate balance of arousing and de-arousing brain activity.” This brain activity involves many different groups of neurons. The over- or underexpression of any of these groups might disturb that “delicate balance,” causing fragmented REM sleep.

This idea fits in with the dominant explanation for chronic insomnia: it’s a manifestation of hyperarousal, which may come about in part due to stress. Stressful life experiences often cause sleep loss. If the poor sleep continues, then sleeplessness and worry about the daytime consequences themselves become stressors and insomnia becomes a chronic affair. The chronic stress accompanying chronic insomnia also leads to changes in the brain. These changes could cause REM sleep fragmentation and disrupted or poor sleep.

Remembering Dreams of Sleeplessness

The idea of REM sleep fragmentation as a driver of sleep maintenance insomnia also fits with the continuity hypothesis of dreaming, which posits that the content of dreams comes from everyday concerns. Not much research exists on the content of insomniacs’ dreams. What is known is summarized in a paper published in Sleep Medicine Reviews:

  • Compared with normal sleepers, insomniacs tended to experience themselves more negatively in their dreams
  • Problems that occurred in dreams were related to current real-life concerns
  • Health problems also appeared more frequently in insomniacs’ dreams.

People with chronic insomnia are prone to worry about sleep loss and its consequences, and these concerns might well dominate the content of our dreams. And if we’re experiencing lots of micro-arousals as we’re dreaming, the content of those dreams would be more accessible to conscious recall. Instead of actually lying awake for hours at night, sleep maintenance insomniacs might be awakening briefly but often to dreams of sleeplessness, making it feel like we’re sleeping less than we are.

Precisely how REM sleep becomes fragmented remains to be seen. But the finding that REM sleep is significantly unstable in sleep maintenance insomniacs is a step in the right direction.

Does the idea of REM sleep instability as a driver of sleep maintenance insomnia seem plausible to you?