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oxfordtreatment.com on substance abuse effects on stress levels

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oxfordtreatment.com on substance abuse effects on stress levels

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Stress is the body's response to outside events or changes, and it may be the result of a single event or an ongoing issue. These events or changes can be good or bad, such as starting a new school, getting married, having a baby, an illness, the death of a loved one, moving, divorce, or getting into an accident. The National Institute of Mental Health(NIMH) reports that there are three main types of stress: routine stress from everyday events, stress resulting from a sudden negative change, or stress as the result of a traumatic event.

When a person feels stressed, changes occur in the mind and body. In some cases, these changes can even be life-saving as the brain engages its "fight-or-flight" reaction in times of high stress or when it perceives itself to be in danger. Heart rate accelerates; blood pressure spikes; body temperature and respiration rates increase; focus, attention, and the senses become dialed in; and the need to sleep and eat are diminished.

Everyone copes with stress in different ways, and some may resort to maladaptive measures of managing stress, which may include abusing drugs. Stress can increase the odds that a person will use drugs; in fact, those exposed to stress are more likely to use mind-altering substances, the National Institute on Drug Abuse (NIDA) warns.
Stress is not always good, however. Chronic stress can have numerous negative effects on the mind and body, including:

Back pain

High blood pressure

Difficulty sleeping

Appetite and weight changes

Lowered immune system functions

Headaches

Diabetes

Depression and anxiety disorders

Anger, irritability, and hostility

Irregular heart functions and heart disease

Stress may also magnify problematic drug use and be a contributing factor in the onset of addiction. The Annals of the New York Academy of Sciencespublishes that stress is a widely accepted risk factor for addiction. People who battle addiction may also be more vulnerable to stress.

Stress, Drugs, and the Brain

Drugs can enact chemical changes in the brain by activating some of the brain's chemical messengers involved in emotional regulation, memory and learning, impulse control, decision-making, happiness, and stress management. Central nervous system depressant drugs, such as opioids (prescription painkillers and heroin) and benzodiazepines (prescription sleep aids, anti-anxiety medications, sedatives, and tranquilizers), slow down heart and respiration rate, body temperature, and blood pressure, enhancing relaxation and sedation. Sedative and tranquilizing drugs increase levels of gamma-aminobutyric acid (GABA) in the brain. GABA slows down the stress response and depresses the fight-or-flight reaction, reducing stress and anxiety, and making these substances a potential target of abuse.

Individuals suffering from high levels of stress, or chronic stress, may use these drugs as a method of managing these symptoms. Individuals who may have difficulties managing stress, poor coping mechanisms, and an inability to control impulses may be at a heightened risk to then use drugs as a result. Drugs can provide an escape from reality while intoxicated and serve to mitigate stress, albeit temporarily.

Most drugs also act on the reward and pleasure center in the brain, causing a burst of euphoria, or a "high," as levels of dopamine and serotonin are increased. In time and with repeated drug use, the brain can rely on drugs to keep levels of its chemical messengers balanced, and drug dependence is often the result.

When someone is dependent on drugs, cravings and drug withdrawal symptoms can be significant when the drugs are not active in the bloodstream. Drug withdrawal symptoms are often in opposition to the drug's desirable effects. Insomnia, depression, physical side effects, and increased levels of anxiety and stress are often the result. People who struggle with drug dependence may resort to continued drug abuse to keep these side effects at bay. Chronic drug use then actually heightens and exacerbates stress, and can lead to a loss of control over when drugs are used and in what amounts.

Addiction and Stress

Similar parts of the brain may be involved in why some people may be more prone to drug abuse and addiction, and to high levels of stress as well. Stress initiates the release of the "stress hormone," called cortisol, in the brain. According to information published in the journal Psychology Today, cortisol can damage healthy brain structure, connectivity, and function in the case of chronic stress. Regions of the brain related to memory and learning, some of the same parts impacted by drug abuse and addiction, are negatively affected with continual levels of high stress and the presence of cortisol. Exposure to stress, particularly at a young age when the brain is still developing, can damage parts of the brain that may then make a person more vulnerable to drug abuse and addiction. In a similar fashion, drug abuse at a young age increases the odds that a person will suffer from addiction later in life, the 2013 National Survey on Drug Use and Health (NSUDH) warns.

Mental illness can be a risk factor for addiction, and vice versa. Drugs may commonly be a form of self-medication for mental illness. The Anxiety and Depression Association of America (ADAA) reports that someone who battles a mood or anxiety disorder is between two and three times more likely to also suffer from drug or alcohol addiction at some point in life. PTSD (post-traumatic stress disorder) is a form of anxiety disorder that occurs when a person is a victim or witness to a potentially life-threatening event and then suffers from flashbacks, reoccurrence symptoms, and an inability to turn off the stress response for an extended time afterwards. PTSD is a common risk factor for drug abuse. The U.S. Department of Veterans Affairs (VA) reports that two out of every 10 veterans suffering from PTSD also battle addiction, while one out of every three who are treated for addiction also suffers from PTSD.
At Oxford Treatment Center we believe not all substance abuse is the same, so neither should its treatment. If you have experienced a traumatic event(s) or struggle with mental health issues such as PTSD, we have designed a customized addiction treatment program with you in mind. Easily compare all of your treatment options in one place.
Stress may trigger drug abuse, and regular drug abuse may induce higher levels of stress. When combined, stress and drug abuse are not a good mix. Together, they increase negative physical and emotional health outcomes and increase a person's vulnerability to addiction, which brings a host of additional social and behavioral concerns.

Effective stress management techniques can detract from a person's desire to use drugs and therefore promote a better quality of life. Proper nutrition, healthy sleep patterns, exercise, and mindfulness meditation are all holistic and complementary forms of managing stress. Making healthy social connections can also help to lower stress levels.

Drug rehab can provide tools for learning healthy coping mechanisms and stress management methods that can be beneficial in sustaining sobriety and a more balanced life. If a person is suffering from drug abuse and high levels of stress, treatment can help.
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How Does Stress Relate to Drug Abuse? - Oxford Treatment Center

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Stress is the body's response to outside events or changes, and it may be the result of a single event or an ongoing issue. These events or changes can be good or bad, such as starting a new school, getting married, having a baby, an illness, the death of a loved one, moving, divorce, or getting into an accident.

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ncbi.nlm.nih.gov on substance abuse effecting stress 

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ncbi.nlm.nih.gov on substance abuse effecting stress 

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Abstract

Stress is a well-known risk factor in the development of addiction and in addiction relapse vulnerability. A series of population-based and epidemiological studies have identified specific stressors and individual-level variables that are predictive of substance use and abuse. Preclinical research also shows that stress exposure enhances drug self-administration and reinstates drug seeking in drug-experienced animals. The deleterious effects of early life stress, child maltreatment, and accumulated adversity on alterations in the corticotropin releasing factor and hypothalamic-pituitary-adrenal axis (CRF/HPA), the extrahypothalamic CRF, the autonomic arousal, and the central noradrenergic systems are also presented. The effects of these alterations on the corticostriatal-limbic motivational, learning, and adaptation systems that include mesolimbic dopamine, glutamate, and gamma-amino-butyric acid (GABA) pathways are discussed as the underlying pathophysiology associated with stress-related risk of addiction. The effects of regular and chronic drug use on alterations in these stress and motivational systems are also reviewed, with specific attention to the impact of these adaptations on stress regulation, impulse control, and perpetuation of compulsive drug seeking and relapse susceptibility. Finally, research gaps in furthering our understanding of the association between stress and addiction are presented, with the hope that addressing these unanswered questions will significantly influence new prevention and treatment strategies to address vulnerability to addiction.

Keywords: chronic stress, early life stress, addiction risk, relapse, craving, mesolimbic dopamine

Introduction

Stress has long been known to increase vulnerability to addiction. The last decade has led to a dramatic increase in understanding the underlying mechanisms for this association. Behavioral and neurobiological correlates are being identified, and some evidence of molecular and cellular changes associated with chronic stress and addiction has been identified. Human studies have benefited from the emergence of sophisticated brain-imaging tools and the cross examination of laboratory-induced methods of stress and craving and their association to specific brain regions associated with reward and addiction risk. This paper focuses primarily on the association between stress and addiction in humans but also draws from the broader animal literature to support the proposed hypotheses. A definition of stress and its neural underpinnings is presented with specific emphasis on its effects on motivation and behavior. In the context of strong epidemiological evidence linking early-childhood and adult adversity and risk of addiction, results from basic and human research that point to putative mechanisms underlying this association are presented. A critical role is seen for prefrontal circuits involved in adaptive learning and executive function, including controlling distress and desires/impulses, in the association between stress and addiction risk. However, several questions remain unanswered in understanding stress-related addiction risk, and these are reviewed in order to inform future research. Finally, the effects of chronic drug use on stress and reward pathways particularly with respect to relapse risk are examined. Future directions in addressing stress-related relapse risk in clinical settings are also discussed.

Stress, Emotions, and Adaptive Behavior

The term "stress" refers to processes involving perception, appraisal, and response to harmful, threatening, or challenging events or stimuli. ⁻ Stress experiences can be emotionally or physiologically challenging and activate stress responses and adaptive processes to regain homeostasis.,⁻ Examples of emotional stressors include interpersonal conflict, loss of relationship, death of a close family member, and loss of a child. Common physiological stressors are hunger or food deprivation, sleep deprivation or insomnia, extreme hyper- or hypothermia, and drug withdrawal states. In addition, regular and binge use of many psychoactive drugs serve as pharmacological stressors. This kind of conceptualization allows the separate consideration of (1) internal and external events or stimuli that exert demands or load on the organism; (2) the neural processes that evaluate the demands and assess availability of adaptive resources to cope with the demands (appraisal); (3) the subjective, behavioral, and physiological activity that signal stress to the organism; (4) neuroadaptations in emotional and motivational brain systems associated with chronic stress; and (5) behavioral, cognitive, and physiological adaptation in response to stressors.

While stress is often associated with negative affect and distress, it can include "good stress" which is based on external and internal stimuli that are mild/moderately challenging but limited in duration and results in cognitive and behavioral responses that generate a sense of mastery and accomplishment, and can be perceived as pleasant and exciting.,,, Such situations rely on adequate motivational and executive functioning to achieve goal-directed outcomes and homeostasis.,, However, the more prolonged, repeated, or chronic the stress-for example, states associated with increased intensity or persistence of distress-the greater the uncontrollability and unpredictability of the stressful situation, lower the sense of mastery or adaptability, and greater the magnitude of the stress response and risk for persistent homeostatic dysregulation.,,⁻ Thus, the dimensions of intensity, controllability, predictability, mastery, and adaptability are important in understanding the role of stress in increasing risk of maladaptive behaviors such as addiction.

The perception and appraisal of stress relies on specific aspects of the presenting external or internal stimuli, personality traits, availability of internal resources (including physiological condition of the individual), prior emotional state (including beliefs and expectancies), and specific brain regions mediating the appraisal of stimuli as distressing, and the resulting physiological, behavioral, and emotional experiences and adaptive responses. Brain regions such as the amygdala, hippocampus, insula, and orbitofrontal, medial prefrontal, and cingulate cortices are involved in the perception and appraisal of emotional and stressful stimuli, and the brain stem (locus ceruleus and related arousal regions), hypothalamus, thalamus, striatal, and limbic regions are involved in physiological and emotional responses. Together these regions contribute to the experience of distress. Physiological responses are manifested through the two major stress pathways, namely corticotropin releasing factor (CRF) released from the paraventricular nucleus (PVN) of the hypothalamus, which stimulates adrenocorticotrophin hormone from the anterior pituitary, which subsequently stimulates the secretion of cortisol/corticosterone from the adrenal glands, and the autonomic nervous system, which is coordinated via the sympathoadrenal medulary (SAM) systems.,

In addition, CRF has extensive influence in extrahypothalamic regions across the corticostriatal-limbic regions and plays a critical role in modulating subjective and behavioral stress responses. Furthermore, central catecholamines, particularly noradrenaline and dopamine, are involved in modulating brain motivational pathways (including the ventral tegmental area or VTA, nucleus accumbens [NAc], and the medial prefrontal [mPFC] regions) that are important in regulating distress, exerting cognitive and behavioral control, and negotiating behavioral and cognitive responses critical for adaptation and homeostasis.,, The hypothalamic and extrahypothalamic CRF pathways and central catechoamines target brain motivational pathways to critically affect adaptive and homeostatic processes. For example, different parts of the medial prefrontal cortex are involved in higher cognitive or executive control functions, such as controlling and inhibiting impulses, regulating distress, focusing and shifting attention, monitoring behavior, linking behaviors and consequences over time, considering alternatives before acting, and decision-making responses., Psychosocial and behavioral scientists have elegantly shown that with increasing levels of emotional and physiological stress or negative affect, there is a decrease in behavioral control and increases in impulsivity, and with increasing levels of distress, and chronicity of stress, greater the risk of maladaptive behaviors. ⁻ Neurobiological evidence shows that with increasing levels of stress, there is a decrease in prefrontal functioning and increased limbic-striatal level responding, which perpetuates low behavioral and cognitive control., Thus, the motivational brain pathways are key targets of brain stress chemicals and provide an important potential mechanism by which stress affects addiction vulnerability.

Stress and the Development of Addictive Behaviors

There is a substantial literature on the significant association between acute and chronic stress and the motivation to abuse addictive substances (see for review). Many of the major theories of addiction also identify an important role of stress in addiction processes. These range from psychological models of addiction that view drug use and abuse as a coping strategy to deal with stress, to reduce tension, to self medicate, and to decrease withdrawal-related distress, ⁻ to neurobiological models that propose incentive sensitization and stress allostasis concepts to explain how neuroadaptations in reward, learning, and stress pathways may enhance craving, loss of control, and compulsion, the key components in the transition from casual use of substances to the inability to stop chronic use despite adverse consequences, a key feature of addiction. ⁻ In this section, we review the converging lines of evidence that point to the critical role that stress plays in increasing addiction vulnerability.

Chronic Adversity and Increased Vulnerability to Drug Use

There is considerable evidence from population-based and clinical studies supporting a positive association between psychosocial adversity, negative affect, and chronic distress and addiction vulnerability. The evidence in this area can be categorized into three broad types. The first includes prospective studies demonstrating that adolescents facing high recent negative life events show increased levels of drug use and abuse. ⁻ Negative life events such as loss of parent, parental divorce and conflict, low parental support, physical violence and abuse, emotional abuse and neglect, isolation and deviant affiliation, and single-parent family structure have all been associated with increased risk of substance abuse.

The second type of evidence is the association between trauma and maltreatment, negative affect, chronic distress, and risk of substance abuse. Overwhelming evidence exists for an increased association between childhood sexual and physical abuse and victimization and increased drug use and abuse. ⁻ There is also some evidence that recent negative life events and physical and sexual abuse each exert somewhat independent risk on addiction vulnerability. In addition to sexual and physical abuse, negative affect and chronic distress states are predictive of addiction vulnerability. Findings indicate that negative affect, including temperamental negative emotionality, is associated with substance abuse risk. ⁻ Several studies have also shown a significant association between prevalence of mood and anxiety disorders, including post-traumatic stress disorder (PTSD), behavioral conduct problems and increased risk of substance use disorders. ⁻ As stress is significantly associated with prevalence of mood and anxiety disorders and chronic psychiatric distress,, these associations raise the issue of whether psychiatric disorders conceptualized as chronic distress states may largely account for the significant association between stress and substance use disorders.

In the third type of evidence from population studies, recent research has examined lifetime exposure to stressors and the impact of cumulative adversity on addiction vulnerability after accounting for a number of control factors such as race/ethnicity, gender, socioeconomic status, prior drug abuse, prevalence of psychiatric disorders, family history of substance use, and behavioral and conduct problems., Cumulative adversity or stress was assessed using a checklist method and by counting the number of different events that were experienced in a given period during the lifespan. The effects of distal (events occurring more than 1 year prior) and proximal stress experiences (events during the most recent 1-year period), and their effects on meeting criteria for substance use disorders were also assessed. The findings indicate that the cumulative number of stressful events was significantly predictive of alcohol and drug dependence in a dose-dependent manner, even after accounting for control factors. Both distal and proximal events significantly and independently affected addiction vulnerability. Furthermore, the dose-dependent effects of cumulative stressors on risk for addiction existed for both genders and for Caucasian, African-American, and Hispanic race/ethnic groups. The types of adverse events significantly associated with addiction vulnerability were parental divorce or conflict, abandonment, forced to live apart from parents, loss of child by death or removal, unfaithfulness of significant other, loss of home to natural disaster, death of a close one, emotional abuse or neglect, sexual abuse, rape, physical abuse by parent, caretaker, family member, spouse, or significant other, victim of gun shooting or other violent acts, and observing violent victimization. These represent highly stressful and emotionally distressing events, which are typically uncontrollable and unpredictable in nature. summarizes the types of life events, chronic stressors, maltreatment, and individual level variables associated with addiction risk.

Possible Mechanisms Underlying Stress Effects on Addiction Vulnerability

However, stress exposure and increased levels of glucocorticoids (GC) also enhance dopamine release in the NAc. ⁻ Suppression of GC by adrenalectomy reduces extracellular levels of dopamine under basal conditions and in responses to stress and psychostimulants., However, chronic GC inhibits DA synthesis and turnover in the NAc, suggesting that alterations in the hypothalamic-pituitary-adrenal (HPA) axis and glucocorticoids can significantly affect DA transmission. There is also evidence that, like drugs of abuse, stress and concomitant increases in CRF and glucocorticoids enhance glutamate activity in the VTA, which in turn enhances activity of dopaminergic neurons. ⁻ Human brain imaging studies have further shown that stress-related increases in cortisol are associated with dopamine accumulation in the ventral striatum,, and some evidence also reveals that amphetamine-induced increases in cortisol are associated with both dopamine binding in the ventral striatum and with ratings of amphetamine-induced euphoria. Given that both stress and drugs of abuse activate the mesolimbic pathways, it is not surprising that each results in synaptic adaptations in VTA dopamine neurons and in morphological changes in the medial prefrontal cortex.,,,

Stress Mechanisms Involved in Acquisition of Drug Self-Administration

Research has also examined whether stress-related increases in acquisition of drug self-administration are mediated by corticosterone (cortisol in humans). Findings indicate that HPA-activated corticosterone release is important for acquisition of drug self-administration.,⁻ Corticosterone administration also facilitates psychomotor stimulant effects of cocaine and morphine. Furthermore, GC receptor antagonists injected into the VTA decrease morphine-induced locomotor activity, suggesting that activity of GC receptors in the VTA could mediate dopamine-dependent behavioral effects. Mice with deletion of the GR gene show a dose-dependent decrease in motivation to self-administer cocaine. These data suggest that HPA-related corticosterone release could at least partially mediate the dopamine increases seen after drug administration.

Although in nonhuman primates the link between cortisol, dopamine, and drug self-administration has not been reported, there is evidence that stress related to social subordination is associated with lower levels of D2 receptors and higher cocaine self-administration. In humans, positive emission tomography (PET) studies using [ ¹¹C]raclopride indicate that acute stress exposure increases dopamine release in the ventral striatum (VS). For example, in a small-sample study, Pruessner and colleagues (2004) found that healthy individuals with low early-life maternal care showed greater dopamine release in the ventral striatum during an acute psychological stress task as compared to those with a history of high early-life maternal care. Furthermore, cortisol response during the stress task was correlated significantly ( r = .78) to VS dopamine release. Oswald and colleagues (2005) also demonstrated that acute amphetamine challenge-related subjective "high" responses and concomitant increase in dopamine in the VS were each significantly associated with amphetamine-induced cortisol responses. More recently, the same group has also shown a similar significant relationship between cortisol levels and dopamine release in the VS using a psychological stress task. Although these data support the link between stress/cortisol and dopamine transmission, human research linking stress-induced changes in VS activity or dopamine binding and risk of addictive behavior is needed to directly establish the association between stress, mesolimbic dopamine, and addiction risk.

Stress, Self-Control, and Addiction Vulnerability

Schematic Model of Stress Effects on Addiction

presents a schematic model of stress effects on addiction. It highlights cross-sensitization of stress and drug abuse on specific behavioral and neurochemical responses and indicates the common neurobiological pathways upon which both stress and drugs of abuse act. Column A lists three types of vulnerability factors: (1) developmental/individual-level factors such as frontal executive function development, negative emotionality, behavioral/self-control, impulsivity, or risk taking, and altered initial sensitivity to rewarding effects of drugs; (2) stress-related vulnerability factors such as early adverse life events, trauma and child maltreatment experiences, prolonged and chronic stress experiences; and (3) genetic influences and family history of psychopathology and addiction, which have not been discussed here but have significant interactive effects on addiction risk and in emotion and stress markers. ⁻ Each of these factors may influence each other to significantly affect alterations in neurobiological pathways involved in stress regulation and cognitive and behavioral control (column B). Specific synaptic changes in these pathways at molecular and cellular levels, provide the basis for the mechanism by which stress and individual and genetic factors in column A interact to increase risk of maladaptive behaviors represented in column C. The model suggests that stress experiences in the presence of these vulnerability factors result in maladaptive stress and self-control responses that increase addiction risk. The specific mechanism by which the maladaptive stress responding increases this risk involves dysregulation in brain stress circuits, particularly the CRF and NE systems, and their interactions with the mesocorticolimbicstriatal dopamine pathways and its modulation by glutamate and GABA.,, Furthermore, recent evidence suggests that stress regulatory molecules, including neuropeptides such as neuropeptide (NPY) endocannabinoids, and neuroactive steroids play a role in addiction vulnerability. ⁻

Drug Use and Abuse and Changes in Stress and Reward Pathways

Stress-Induced Reinstatement of Drug Seeking and Relapse

Human research has also begun to identify markers of the stress and craving states that are predictive of relapse outcomes. To fully understand whether the increased distress and drug-craving state is predictive of relapse, we followed the inpatient treatment-engaged cocaine- and alcohol-dependent individuals in our studies described in previous sections after discharge from inpatient treatment for 90 days to assess relapse outcomes. For the cocaine group, we found that stress-induced cocaine craving in the laboratory significantly predicted time to cocaine relapse. While stress-induced ACTH and cortisol responses were not associated with time to relapse, these responses were predictive of amounts of cocaine consumed during follow-up. While drug cue-induced craving was not predictive of relapse in this study, there was a high correlation between stress and drug cue-induced drug craving and in stress and drug cue-induced HPA responses. These data suggest that at least in the case of cocaine dependence, stress and drug cue-induced distress states produce a similar compulsive drug-seeking state that is associated with relapse vulnerability. In alcoholics, negative mood, stress-induced alcohol craving, and blunted stress and cue-induced cortisol responses have been associated with alcohol relapse outcomes.,⁻ Nicotine-deprived smokers who were exposed to a series of stressors showed blunted ACTH, cortisol, and blood pressure responses to stress but increased nicotine withdrawal and craving scores, and these responses were predictive of nicotine relapse outcomes. Thus, for alcoholic and smoking samples, as in the cocaine group, it appears that the drug-craving state marked by increasing distress and compulsive motivation for drug (craving) along with poor stress regulatory responses (altered glucocorticoid feedback or increased noradrenergic arousal) results in an enhanced susceptibility to addiction relapse.

Findings from basic science and human laboratory and clinical outcome studies identify several pharmacological treatment targets to address stress-induced reinstatement of drug seeking and relapse susceptibility. Basic science data suggest CRF antagonists, alpha-2 adrenergic agonists, and glutamatergic agents could be promising in addressing stress-related relapse. Human laboratory studies are needed that will screen these agents to assess their promise with regard to intermediate markers of stress-related relapse susceptibility. Such studies would target stress- and cue-induced drug craving, craving-related anxiety, HPA measures, and heart rate or heart rate variability as well as responses in specific brain regions. For example, in a preliminary laboratory and clinical outcomes study, we have shown that lofexidine, an alpha-2 adrenergic agonist, significantly decreased stress-induced opiate craving and stress-induced anger ratings, while also improving opiate relapse outcomes in naltrexone-treated, opiate-dependent individuals. Similarly, behavioral strategies that decrease anxiety and stress-related drug craving and normalize stress responses so as to potentiate adaptive responding in high-challenge contexts would be of benefit in decreasing the effects of stress on drug seeking and relapse. For example, mindfulness based stress reduction (MBSR) is efficacious in decreasing relapse to major depression, and adaptations of these strategies could be of benefit to address relapse risk in addiction.

Summary and Future Directions

This review focuses on the accumulating evidence from preclinical, clinical, and population studies that highly stressful situations and chronic stress increase addiction vulnerability, that is, both risk of developing addiction and risk of relapse. The types of stressors that increase addiction risk are identified in . The stressors tend to be highly emotionally, distressing events that are uncontrollable and unpredictable for both children and adults. The themes range from loss, violence, and aggression to poor support, interpersonal conflict, isolation, and trauma. There is also evidence for a dose-dependent relationship between accumulated adversity and addiction risk-the greater the number of stressors an individual is exposed to, the higher the risk of developing addiction. Work-related stressors have weaker support, but individual-level variables such as trait negative emotionality and poor self-control (possibly similar to poor executive function) appear to also contribute uniquely to addiction risk. Exposure to such stressors early in life and accumulation of stress (chronicity) result in neuroendocrine, physiological, behavioral, and subjective changes that tend to be long lasting and adversely affect development of brain systems involved in learning, motivation, and stress-related adaptive behaviors. Research that directly addresses stress-related neurobiological changes and their association with behavioral outcomes is sorely needed. Evidence to clarify the contribution of stress to alterations in mesolimbic dopamine activity and its association with drug use is also needed. presents a schematic model of associations that have been supported in research, as well as remaining gaps.

A review of evidence indicating the effects of drug use and abuse on stress responses and dopamine transmission is presented, along with altered emotional and motivational responses associated with craving and relapse to drug use. While substance abuse results in changes in stress and dopaminergic pathways involved in motivation, self control, and adaptive processes necessary for survival, evidence for whether such changes enhance drug seeking or craving and drug use behaviors is lacking. For example, studies on whether prior exposure to licit and illicit drugs modifies the association between stress and drug self-administration are rare. While there are specific neuroadaptations in reward and associated regions, it is also important to examine which of these changes are involved in increasing drug intake and supportive of addictive processes such as progressive loss of control, persistence of craving, and escalating drug self-administration. As stress also increases risk of mood and anxiety disorders that are highly comorbid with addiction, it is important to examine whether there are specific stress-related factors that contribute to risk for mood and anxiety disorders and addiction risk. That is, what are the resiliency factors that are protective for one set of illness but are vulnerabilities for the other. Exploration of gene-environment interactions could be particularly helpful in answering such questions.

A review of recent studies on stress-induced reinstatement to drug seeking, drug craving, and relapse susceptibility is also provided. Clinical implications include the development of new assessment procedures and markers that will be useful in identifying those who are at particular risk for stress-related relapse and testing of novel pharmacological therapies that target the link between stress and relapse risk. As shown in , addicted individuals show enhanced sensitivity to craving and greater anxiety in stress- and drug-related situations, but whether such altered responses represent transitions due to chronic drug use or chronic stress states needs to be further examined. Research on the mechanisms by which chronic stress and drug use alter executive functions that are involved in adaptive behavioral responses is needed. Efficacious behavioral treatments focus on improving coping response. However, stress exposure and chronic distress decrease stress adaptive and coping mechanisms, and hence treatments that focus on enhancing coping may not be suitable for those with stress-related risk factors. Development of new interventions that target self-control, especially in the context of stress is needed. Systematic research on these questions will lead to a greater understanding of how stress is associated with relapse. Furthermore, such research may be significant in developing new treatment targets to reduce relapse, both in the area of medication development and in developing behavioral treatments that specifically target the effects of stress on continued drug use and relapse in addicts.

Acknowledgments

Preparation of this review was supported by grants from the National Institutes of Health, P50-DA165556, R01-AA13892, R01-DA18219, and U01-RR24925.

Footnotes

Conflicts of Interest

The author declares no conflicts of interest.

References

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Chronic Stress, Drug Use, and Vulnerability to Addiction

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Stress is a well-known risk factor in the development of addiction and in addiction relapse vulnerability. A series of population-based and epidemiological studies have identified specific stressors and individual-level variables that are predictive of substance use and abuse. Preclinical research also shows that stress exposure enhances drug self-administration and reinstates drug seeking in drug-experienced animals.

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med.harvard.edu effects of sleep on stress levels 

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med.harvard.edu effects of sleep on stress levels 

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The Link Between Sleep and Mood

You probably know firsthand that sleep affects mood. After a sleepless night, you may be more irritable, short-tempered, and vulnerable to stress. Once you sleep well, your mood often returns to normal.

Studies have shown that even partial sleep deprivation has a significant effect on mood. University of Pennsylvania researchers found that subjects who were limited to only 4.5 hours of sleep a night for one week reported feeling more stressed, angry, sad, and mentally exhausted. When the subjects resumed normal sleep, they reported a dramatic improvement in mood.

Not only does sleep affect mood, but mood and mental states can also affect sleep. Anxiety increases agitation and arousal, which make it hard to sleep. Stress also affects sleep by making the body aroused, awake, and alert. People who are under constant stress or who have abnormally exaggerated responses to stress tend to have sleep problems.

Sleep and Mood (0:49)
Dr. Lawrence J. Epstein describes the relationship between sleep and mood.

Insomnia and Psychological Problems

"There's a big relationship between psychiatric and psychological problems and sleep. So people who are depressed or have anxiety often have trouble with sleep as part of those disorders," says Dr. Lawrence Epstein, Medical Director of Sleep Health Centers and an instructor at Harvard Medical School.

Difficulty sleeping is sometimes the first symptom of depression. Studies have found that 15 to 20 percent of people diagnosed with insomnia will develop major depression. While sleep research is still exploring the relationship between depression and sleep, studies have shown that depressed people may have abnormal sleep patterns.

Sleep problems may, in turn, contribute to psychological problems. For example, chronic insomnia may increase an individual's risk of developing a mood disorder, such as depression or anxiety. In one major study of 10,000 adults, people with insomnia were five times more likely to develop depression. Lack of sleep can be an even greater risk factor for anxiety. In the same study, people with insomnia were 20 times more likely to develop panic disorder (a type of anxiety disorder). Another study showed that insomnia is a reliable predictor of depression and many other psychiatric disorders, including all types of anxiety disorders.

Addressing Sleep Problems Makes a Difference

If you sleep poorly and feel depressed, anxious, or less emotionally responsive, there are many treatments that can help. First, look at your sleep habits and see if there are steps that you can take on your own to improve the quantity and quality of your sleep. See Adopt Good Sleep Habits for tips on how to improve your sleep. If problems persist, you may wish to see a medical provider and ask about an evaluation for sleep problems and mental health concerns. After an evaluation and diagnosis, your provider can advise you on the best course of treatment. Options may include behavioral or other forms of therapy and/or medications. You can read about and watch a video of a behavioral sleep consultation in the Healthy Sleep module.

Even if you do not have underlying sleep problems, taking steps to ensure adequate sleep will lead to improved mood and well-being. Sheila, a Boston district attorney and mother, became sleep deprived due to the conflicting demands of a full-time job and caring for her young children. She began to feel cranky, irritable, and uncharacteristically depressed. When she got both of her children on a consistent sleep schedule, she herself started sleeping an average of seven to eight hours a night and her mood improved considerably. Read more and watch a video about this in Sheila's Balancing Act.

References

1. Dinges, D. et al., Cumulative Sleepiness, Mood Disturbance, and Psychomotor Vigilance Decrements During a Week of Sleep Restricted to 4 - 5 Hours Per Night, Sleep. 1997 Apr; 20 (4): 267-277.

2. Breslau, N. et al., Sleep Disturbance and Psychiatric Disorders: A Longitudinal Epidemiological Study of Young Adults, Biological Psychiatry. Mar 1996; 39(6): 411-418.

3. Nofzinger, E., Functional Neuroimaging of Sleep, Seminars in Sleep Neurology. 2005 Mar; 25 (1): 9-18.

4. Neckelmann, D. et al., Chronic Insomnia as a Risk Factor for Developing Anxiety and Depression, Sleep. 2007; 30 (7): 873-880.

5. Ibid.

6. Weissman, M. et al., The Morbidity of Insomnia Uncomplicated by Psychiatric Disorders, General Hospital Psychiatry.1997; 19(4): 245-250.

This content was last reviewed on December 15, 2008

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You probably know firsthand that sleep affects mood. After a sleepless night, you may be more irritable, short-tempered, and vulnerable to stress. Once you sleep well, your mood often returns to normal. Studies have shown that even partial sleep deprivation has a significant effect on mood.

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sleepfoundation.org effects of sleep leading to stress

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2020 has been a stressful year for people in the U.S. According to results from the American Psychological Association's Stress in America 2020 survey, general stress levels are significantly above average compared to years past. In fact, this year's respondents reported the highest average stress levels since the survey was first launched in 2007 - 5.4 out of 10, an increase of 0.5 since last year. These figures can largely be attributed to COVID-19 and its implications on finances, parenting, and other aspects of daily life.

Stress and anxiety often lead to insomnia and sleep problems. By the same token, lack of proper rest can contribute to stress. And because stress and sleep problems share such a reciprocal relationship, addressing one of these issues can often lead to improvements for the other.

Stress and the Body

The network known as the hypothalamic-pituitary-adrenal (HPA) axis regulates your body's hormonal response to stressful situations. The hypothalamus - a cluster of nuclei located in the brain - will instruct the pituitary gland to release a hormone, and then the pituitary gland will signal the adrenal glands to produce steroid hormones called glucocorticoids. Two of these glucocorticoids are cortisol and adrenaline, which are also known as stress hormones.

The body naturally produces cortisol throughout the day, with levels spiking immediately after we wake up and gradually decreasing throughout the day. This added cortisol regulated by the HPA is the reason why you often feel hyper-alert during stressful situations, but this can cause you to "crash" once the stress subsides.

Stress can take many forms, but these feelings generally fall into one of three categories:

Acute stress: This type of short-term stress often accompanies fleeting moments of panic or dread. Examples include realizing you've missed a deadline for work or school, or nearly being involved in a car accident. You may notice upticks to your blood pressure and heart rate, followed by feelings of irritability, sadness, and anxiety. Some people also experience headaches, back pain, and gastrointestinal issues. However, the symptoms of acute stress typically subside after a short time.

Episodic acute stress: This type of stress is essentially an accumulation of individual moments of acute stress. People who feel burdened by day-to-day struggles may attempt to alleviate their frustrations through unhealthy behaviors like overeating or binge drinking. Other serious complications of episodic acute stress include clinical depression and heart disease, as well as poor performance at work and relationship problems.

Chronic stress: Many factors can contribute to chronic stress, including poverty, abuse, and trauma. People tend to internalize these painful experiences, and over time this can wear down the mind and lead to feelings of hopelessness. Chronic stress can also cause deficiencies related to how the HPA axis processes stressful situations and communicates with the rest of the body.

While moderate amounts of acute stress pose very little risk to your health, chronic stress can have a major impact on your body. These effects can be felt in various ways and throughout different bodily systems, including:

Cardiovascular: The body's "fight or flight" response to acute stress causes your heart rate and blood pressure to spike, and also increases contractions in your heart muscles. Cortisol and adrenaline act as messengers that regulate these functions. After the moment of acute stress is over, the body will stabilize. Chronic stress can cause long-term heart problems because your heart rate and blood pressure are constantly elevated, which puts added pressure on the cardiovascular system. This increases your risk for hypertension, heart attack, and stroke, and can also cause inflammation to your circulatory system.

Gastrointestinal: The gut is loaded with nerves and bacteria that communicate with the brain in order to regulate mood and promote overall bodily health. Stressful moments can interfere with this communication, leading to pain, bloating, and other types of gastrointestinal discomfort. These situations can also lead to loss of appetite, which can have a negative impact on digestive health if it impacts what and when you eat. Obesity may also be an issue for people who overeat when they are anxious. Additionally, stress can weaken the intestinal barriers that prevent harmful bacteria from entering the stomach, and also cause painful spasms in the esophagus and bowels.

Musculoskeletal: You may notice your muscles tensing up during stressful moments. This reflexive feeling is the body protecting you from potential pain or harm, and it is caused by dilating blood vessels in the arms and legs. Chronic stress can cause persistent muscle tension, which in turn may lead to other problems such as migraine headaches or lower back and upper extremity pain. In cyclical fashion, the discomfort of this constant tension can also contribute to long-term stress.

Nervous: During moments of acute stress, the nervous system transmits signals between the pituitary gland and adrenal glands to facilitate production of adrenaline and cortisol. The nervous system also regulates the "comedown" period immediately following a temporarily stressful situation. Chronic stress can overwork your nerves and wear down the body over time.

Reproductive: Stress can cause issues in the reproductive systems of men and women. Chronic stress can lead to diminished sexual desire for both sexes and leave them more vulnerable to cancers and other diseases that affect reproductive parts. Men may experience decreases in the size and swimming capabilities of their sperm, whereas women may have trouble conceiving. Chronic stress in pregnant women can also impact fetal and childhood development.

Respiratory: Stressful situations can lead to both shortness of breath or rapid breathing. Acute stress may trigger asthma attacks and other problems for people with pre-existing respiratory conditions. Over time, chronic stress can lead to more serious conditions such as chronic obstructive pulmonary disease.

How Does Stress Affect Sleep?

Insomnia is a common sleep disorder derived from stress. Insomnia is defined as persistent difficulty with sleep onset, maintenance, consolidation, or overall quality. It occurs despite adequate time allotted for sleep on a given night and a comfortable place to sleep, and people with insomnia experience excessive daytime sleepiness, fatigue, irritability and other impairments when they are awake. Current estimates suggest 10-30% of adults live with insomnia.

A person may be diagnosed with chronic insomnia if their symptoms occur at least three times per week for at least three months. Persistent stressors can heavily contribute to chronic insomnia. These stressors may include:

Problems or dissatisfaction at work

Divorce and other marital or family difficulties

The death of a loved one

Major illness or injury

Crucial life changes

Not everyone develops chronic insomnia due to constant stress, but those with anxiety disorder are at higher risk of experiencing insomnia symptoms. Additionally, changes to one's sleep schedule that occur due to life events or changes can also lead to insomnia. Once chronic insomnia takes hold, people often feel anxious about sleeping and other aspects of their lives. This increases day-to-day stress, which in turn exacerbates insomnia symptoms.

Other daytime impairments related to insomnia that can bring about or contribute to stress include:

Feelings of fatigue and malaise

Difficulty paying attention, concentrating, or accessing memories

Impaired performance in social, family, professional, or academic settings

Irritability and mood disturbances

Hyperactivity, aggression, impulsivity, and other behavioral issues

Decreased energy and motivation

Increased risk for errors and accidents

If someone experiences insomnia symptoms for fewer than three months, then this condition is referred to as short-term insomnia. Just as chronic stress can precipitate chronic insomnia, acute stressors can bring about short-term insomnia symptoms. These stressors may include:

Interpersonal relationship issues

Work-related problems

Financial loss

Grieving and bereavement

Diagnosis or initial symptoms of a disease or other medical condition

Acute stress may also occur if you've made significant changes to your bedroom or sleep area. For example, new parents may experience insomnia symptoms when sharing their bedroom with their baby for the first time, even if the child is not audibly disruptive. Children may also have sleep problems immediately after they begin sharing their room with a sibling. Visiting or moving to a new location can lead to short-term insomnia, as well.

Short-term insomnia symptoms may begin to dissipate once the stressful situation ends and acute stress subsides. However, some people fall into a vicious pattern of sleep loss and daytime anxiety about sleep that eventually snowballs into chronic insomnia.

In addition to insomnia, chronic stress can lead to sleep apnea. This sleep disorder is characterized by a recurring collapse of the upper airway during sleep, which can cause heavy snoring and choking episodes along with excessive daytime sleepiness and other daytime impairments. Hypertension, heart disease, diabetes, and other medical conditions that can often be attributed to stress are predisposing factors for sleep apnea. Obesity is also considered a major risk factor. And like insomnia, sleep apnea can exacerbate stress by disrupting your sleep and wearing you down during the day.

Does Sleep Help Stress?

Getting enough sleep on a nightly basis can alleviate stress quite effectively. Unfortunately, a good night's rest can be elusive if you're stressed out - especially if sleep problems are a major source of your day-to-day anxieties.

There are other measures you can take to relieve stress. These include regularly exercising and maintaining a healthy support network of friends and family. However, keeping stress at bay often demands adequate sleep. National Sleep Foundation guidelines advise that healthy adults should sleep between seven and nine hours each night.

How to Sleep When Stressed

Stress management is key to a good night's sleep, and how well you manage stress can depend on your day-to-day lifestyle. In addition to following a balanced diet and exercising throughout the week, you can alleviate stress through controlled breathing and other relaxation techniques. A healthy work-life balance is also important, as is your ability to productively "release" stress during situations that cause stress, and not at other moments.

Proper sleep hygiene can also improve your sleep quality and duration, leaving you more refreshed in the morning and prepared to manage stress. Sleep hygiene guidelines include:

Strict sleep schedule: Go to bed and wake up at the same times each day. This includes on the weekends and when you're traveling or on vacation.

Optimal bedroom atmosphere: Your bedroom should have a relaxing effect when you are ready for sleep. You should keep the lights dim and reduce exposure to outside noise. A comfortable temperature is also key; experts generally recommend 60 to 67 degrees, though 65 degrees is considered the ideal.

No electronics: Televisions, computers, cell phones, and other electronic devices emit a blue light that can interfere with sleep. For best sleep results, keep these devices out of your bedroom at all times.

Reduced evening intake: Avoid consuming nicotine and caffeine in the hours leading up to bedtime. These stimulants can keep you feeling alert when it's your normal time for sleep. Alcohol can also be problematic for sleep. Many people think drinking helps sleep because of alcohol's sedative properties, but you may experience sleep fragmentation as your body processes and breaks down the alcohol. Lastly, you should avoid large meals before bed.

Regular exercise: Moderate exercise in the morning or early afternoon can help you wind down and fall asleep more easily at night.

Laying in bed when you are too stressed to sleep can be counterproductive. If you haven't gone to sleep within 15 minutes of going to bed, try getting up and relocating to another area of your residence for a relaxing activity such as reading, meditating, or listening to calming music; avoid watching TV or other activities that involve blue light devices.

Some people also experience anxiety when they wake up in the middle of the night and see the time on their bedside clock. Avoid looking at your clock if you wake up - cover the display if necessary.

If your sleep problems persist, you should see your doctor or another credentialed physician. This may lead to an insomnia diagnosis and treatment for your insomnia symptoms.

Other Stress Management Tips

Some people find stress relief through cognitive behavioral stress management (CBSM). This form of short-term therapy pinpoints the way your thoughts and beliefs affect how you behave and interact with the world around you. By identifying irrational or inaccurate thoughts and replacing them with more positive ones, you may be able to change your behaviors and your general outlook.

Studies have shown CBSM can be an effective measure for various groups that tend to experience undue stress, such as professional nurses, people with substance abuse disorders, and individuals living with HIV.

Incidentally, cognitive behavioral therapy has also proven effective for alleviating insomnia symptoms. Known as CBT-i for short, this type of therapy helps people overcome misconceptions or negative beliefs about sleep in order to get more rest and overcome their insomnia. CBT-i emphasizes sleep restriction and the importance of getting out of bed on sleepless nights, as well as proper sleep hygiene and relaxation techniques.

In addition to following sleep hygiene guidelines and pursuing CBSM therapy, many people effectively manage their stress by taking the following measures:

Learn to recognize stress: Stress elicits different reactions from everyone. They may include trouble sleeping, dependence on alcohol or drugs, feelings of irritability and anger, or low levels of energy and motivation. Recognizing these reactions is key to understanding when you're stressed.

Engage in relaxing activities: When performed correctly, meditation, muscle relaxation, and controlled breathing exercises can all help alleviate stress. Incorporating these wellness activities into your regular routine can reduce stress to a significant degree.

Create goals for yourself: Giving up and not caring about what comes next are hallmarks of desperation. Stress, especially at the chronic level, can induce these negative feelings. Maintain a positive mindset by setting reasonable goals in your social, family, and professional life.

Reach out to your support system: Maintaining consistent communication lines with your friends and family members can reduce stress through emotional support. Some people also find comfort through connecting with community groups and religious organizations.

Initiate the "stress talk" with your doctor: Stress, when unchecked, can quickly become overwhelming. Take a proactive approach toward stress management by scheduling an appointment with your doctor or mentioning stress during your next checkup.

You should see your doctor or another physician immediately if you're experiencing suicidal thoughts, abusing drugs or alcohol, or feeling that you can't cope with day-to-day life due to stressors. You can also call the National Suicide Prevention Lifeline at 1-800-273-8255 (1-800-273-TALK). The lifeline also offers 24-hour live online chat on their website, as well.

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2020 has been a stressful year for people in the U.S. According to results from the American Psychological Association's Stress in America 2020 survey, general stress levels are significantly above average compared to years past.

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Stressed out without enough sleep

Sleep is a necessary human function - it allows our brains to recharge and our bodies to rest. ¹ When we do not sleep long or well enough, our bodies do not get the full benefits of sleep, such as muscle repair and memory consolidation. ² Sleep is so crucial that even slight sleep deprivation or poor sleep can affect memory, judgment and mood. ³ In addition to feelings of listlessness, chronic sleep deprivation can contribute to health problems, from obesity and high blood pressure to safety risks while driving. ⁴ Research has shown that most Americans would be happier, healthier and safer if they were to sleep an extra 60 to 90 minutes per night. ⁵

This year's Stress in America™ survey shows that stress may be interfering with Americans' sleep, keeping many adults and teens from getting the sleep they need to be healthy.

Survey findings show that stress may be getting in the way of quality sleep. American adults report sleeping an average of 6.7 hours a night - less than the minimum recommendation of seven to nine hours. ⁶ In addition, 42 percent of adults report that their sleep quality is fair or poor and 43 percent report that stress has caused them to lie awake at night in the past month.

Many report that their stress increases when the length and quality of their sleep decreases.

When they do not get enough sleep, 21 percent of adults report feeling more stressed. Adults with higher reported stress levels (eight, nine or 10 on a 10-point scale) fare even worse - 45 percent feel even more stressed if they do not get enough sleep. Five percent of adults with lower reported stress levels (one, two or three on the 10-point scale) say the same.

Only 20 percent of adults say the quality of their sleep is very good or excellent.

Thirty-seven percent of adults report fatigue or feeling tired because of stress.

Many adults report negative consequences from not getting enough sleep. More than half (53 percent) report feeling sluggish or lazy, 38 percent report feeling irritable, 29 percent report they have trouble concentrating and 25 percent report feeling no motivation to take care of responsibilities.

Adults who sleep fewer than eight hours a night report higher stress levels than those who sleep at least eight hours a night (5.5 vs. 4.4 on a 10-point scale).

On average, adults with lower reported stress levels report sleeping more hours a night than do adults with higher reported stress levels (7.1 vs. 6.2 hours). They are also more likely to say they have excellent or very good-quality sleep (33 percent vs. 8 percent) and get enough sleep (79 percent vs. 33 percent).

Adults who sleep fewer than eight hours a night are more likely to report symptoms of stress in the past month, such as feeling irritable or angry, than adults who sleep more than eight hours a night (45 percent vs. 32 percent of adults); feeling overwhelmed (40 percent vs. 27 percent); lacking interest, motivation or energy (42 percent vs. 30 percent); losing patience or yelling at their children (52 percent vs. 27 percent); losing patience or yelling at their spouse or partner (50 percent vs. 36 percent); and skipping exercise (41 percent vs. 33 percent). They are also more likely to say their stress has increased in the past year (40 percent vs. 25 percent).

Adults with high stress are more likely to say they are not getting enough sleep because their minds race (49 percent vs. 10 percent of adults with low stress).

Adults with high stress are also more likely than those with low stress to say they feel the effects of getting too little sleep:

Sixty-eight percent say they feel sluggish or lazy versus 36 percent of adults with low stress.

Fifty-nine percent say they are irritable versus 20 percent of adults with low stress.

Forty-five percent say they have trouble concentrating versus 12 percent of adults with low stress.

Forty-five percent say they feel more stressed versus five percent of adults with low stress.

Twenty-seven percent say they feel sad or depressed versus two percent of adults with low stress.

Stress also affects teens' sleep

Teens also report that stress has an impact on their sleep and vice versa. Teens report sleeping far less than the minimum age-based recommendation of 8.5 to 9.25 hours. ⁷ On average, teens say they sleep 7.4 hours a night on a school night and 8.1 hours a night on a non-school night. Nearly one-quarter of teens (24 percent) also report that their sleep quality is fair or poor.

More than one-third of teens (35 percent) report that stress caused them to lie awake at night in the past month. And for teens who sleep fewer than eight hours per school night, many say their stress level has increased over the past year (42 percent), compared with 23 percent of teens who sleep at least eight hours per school night. In addition, 18 percent of teens say that when they do not get enough sleep, they are more stressed and 36 percent of teens report feeling tired because of stress in the past month. Thirty-nine percent of teens with higher reported stress levels (eight, nine or 10 on a 10-point scale) during the past school year feel even more stressed if they do not get enough sleep, while only 3 percent of teens with lower reported stress levels (one, two or three on a 10-point scale) during the past school year say the same.

When they do not sleep enough, more than half of teens (53 percent) report feeling sluggish or lazy and 42 percent say they feel irritable. Thirty-two percent say they are unable to concentrate and 23 percent report feeling no motivation to take care of responsibilities.

Teens with low stress during the past school year report sleeping more hours per night than do teens with high stress (7.8 vs. 6.9 hours).

Ninety percent of teens with low reported stress levels during the past school year say they get enough sleep, compared to less than half (48 percent) of teens with high reported stress levels during the past school year.

Teens with lower reported stress levels during the past school year are also more likely than highly stressed teens to say they have excellent or very good-quality sleep (59 vs. 22 percent). Teens with high reported stress levels during the past school year are more likely to report having trouble sleeping well - 43 percent say they do not get enough sleep because their mind races, compared to 9 percent of teens with low stress who say the same.

Teens who report experiencing high stress during the past school year are also more likely than those who report having low stress to say they feel the effects of getting too little sleep:

Sixty-one percent of highly stressed teens say they feel sluggish or lazy versus 42 percent of teens with low stress.

Fifty-four percent of highly stressed teens say they are irritable versus 25 percent of teens with low stress.

Forty-four percent of highly stressed teens say they have trouble concentrating versus 20 percent of teens with low stress.

Thirty-nine percent of highly stressed teens say they are more stressed versus three percent of teens with low stress.

Twenty-six percent of highly stressed teens say they feel sad or depressed versus one percent of teens with low stress.

When it comes to stress, teens who get fewer than eight hours of sleep on a school night appear to fare worse than teens getting eight hours of sleep on school nights:

Teens who sleep fewer than eight hours per school night report higher stress levels in the past month than teens who sleep at least eight hours per school night (5.2 vs. 4.1 on a 10-point scale).

Teens who sleep fewer than eight hours on a school night are more likely than teens who sleep at lease eight hours on a school night to report experiencing symptoms of stress, such as feeling irritable or angry (50 percent vs. 32 percent), nervous or anxious (46 percent vs. 28 percent), depressed or sad (43 percent vs. 18 percent) and overwhelmed (42 percent vs. 22 percent).

Younger generations are not sleeping well, often due to stress

Younger Americans (Millennials and Gen Xers) report getting fewer hours of sleep per night on average, and are more likely than other adults to say they do not get good-quality sleep and have more trouble achieving their sleep goals. ⁸ Younger adults are more likely to say they feel stressed by a lack of sleep (Millennials: 29 percent; Gen Xers: 23 percent) than Boomers (19 percent) and Matures (7 percent). Millennials and Gen Xers are also more likely to report feeling sad or depressed because of stress (Millennials: 47 percent; Gen Xers: 42 percent; Boomers: 29 percent; Matures: 15 percent).

Gen Xers are most likely to say that they sleep fewer than eight hours a night (77 percent vs. 74 percent of Boomers, 66 percent of Matures and 64 percent of Millennials). They are also least likely to say they are getting enough sleep (45 percent vs. 74 percent of Matures, 56 percent of Boomers and 54 percent of Millennials).

Half of Gen Xers (49 percent) say their sleep quality is fair or poor, compared to 43 percent of Millennials, 42 percent of boomers and 28 percent of matures.

Only 24 percent of Gen Xers say they are doing a very good or excellent job at getting enough sleep, despite the majority of this generation (61 percent) who say that getting enough sleep is extremely or very important to them. A wide gap between perceived importance and achievement of sleep goals also exists for Millennials (59 percent vs. 28 percent), Boomers (64 percent vs. 30 percent) and Matures (70 percent vs. 50 percent).

Gen Xers and millennials are most likely to say lack of sleep makes them irritable (49 percent and 47 percent, respectively, vs. 30 percent of Boomers and 15 percent of Matures).

While Gen Xers report sleeping the fewest hours, Millennials report poorer sleep habits than other adults. In particular, Millennials are more likely to say they do not get at least eight hours of sleep because they stay up too late (52 percent compared with 36 percent of Gen Xers, 29 percent of Boomers and 22 percent of Matures).

Nearly one-third of Millennials also attribute lack of sleep to thinking of all the things they need to do or did not get done (31 percent compared with 27 percent of Gen Xers, 24 percent of Boomers and 14 percent of Matures).

More than one-third of Millennials say they do not sleep at least eight hours a night because they have too many things to do and do not have enough time (35 percent compared with 19 percent of Gen Xers, 13 percent of Boomers and 6 percent of Matures).

Younger Americans are also more likely to report consequences of unhealthy sleeping habits. When they do not get enough sleep, 60 percent of Millennials say they feel sluggish or lazy, compared to 58 percent of Gen Xers, 50 percent of Boomers and 37 percent of Matures; 38 percent of Millennials say they have trouble concentrating on things they need to do, compared to 32 percent of Gen Xers, 27 percent of Boomers and 11 percent of Matures; and 34 percent of Millennials say they are not motivated to take care of responsibilities, compared to 23 percent of Gen Xers, 22 percent of Boomers and 14 percent of Matures.

¹Division of Sleep Medicine at Harvard Medical School and WGBH Educational Foundation. (n.d.). Why do we sleep, anyway? Healthy Sleep . Retrieved from http://healthysleep.med.harvard.edu/healthy/matters/benefits-of-sleep/why-do-we-sleep.

²National Sleep Foundation. (n.d.). What happens when you sleep? Retrieved from http://www.sleepfoundation.org/article/how-sleep-works/what-happens-when-you-sleep.

³Division of Sleep Medicine at Harvard Medical School and WGBH Educational Foundation. (n.d.). Consequences of insufficient sleep. Healthy Sleep. Retrieved from http://healthysleep.med.harvard.edu/healthy/matters/consequences.

⁴Spira, A. P., Gamaldo, A. A., An, Y., Wu, M. N., Simonsick, E. M., Bilgel, M., ... & Resnick, S. M. (2013, October). Self-reported sleep and β-amyloid deposition in community-dwelling older adults. The Journal of the American Medical Association Neurology. doi:10.1001/jamaneurol.2013.4258.

⁵American Psychological Association. (2004, May). More sleep would make most Americans happier, healthier and safer. Retrieved from http://www.apa.org/research/action/sleep-deprivation.aspx.

⁶National Sleep Foundation. (n.d.). How much sleep do we really need? Retrieved from http://www.sleepfoundation.org/article/how-sleep-works/how-much-sleep-do-we-really-need.

⁷ Ibid.

⁸ The four generations are defined as the following: Millennials (18- to 34-year-olds), Gen Xers (35- to 48-year-olds), Boomers (49- to 67-year-olds) and Matures (68 years and older).

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Stressed out without enough sleep Sleep is a necessary human function - it allows our brains to recharge and our bodies to rest. 1 When we do not sleep long or well enough, our bodies do not get the full benefits of sleep, such as muscle repair and memory consolidation.

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Taking care of your long-term mental and physical health is an important part of stress management. However, there isn't always time to take a nap, hike a fourteener, or read a novel. Thus, here are 25 ways to reduce stress in five minutes or less. From eating chocolate to meditating, there is a quick stress-relieving tactic for everyone.

1. Breathe
Slow, deep breaths can help lower blood pressure and heart rate. Try pranayama breathing, a yogic method that involves breathing through one nostril at a time to relieve anxiety. The technique is supposed to work the same way as acupuncture, balancing the mind and body.

5. Give Yourself a Hand Massage
When there's no professional masseuse in sight, try DIYing a hand massage for instant relaxation that calms a pounding heart. Hands in general can carry a lot of tension. Apply some lotion and start kneading the base of the muscle under the thumb to relieve stress in the shoulders, neck, and scalp.

11. Try Progressive Relaxation
Anxious? Just squeeze, release, and repeat. Progressive relaxation involves tensing the muscles in one body part at a time to achieve a state of calm. The method ( also used by actors) is a great way to help fall asleep.

15. Eat Some Chocolate
Just a square (about 1.4 ounces) of the sweet stuff can calm your nerves. Dark chocolate regulates levels of the stress hormone cortisol and stabilizes metabolism.

16. Meditate
Five minutes of peace is all it takes to reap the benefits of meditation. There's evidence that just two quick bouts of silent meditation per day can relieve stress and depression. Find a comfortable spot in a quiet place, focus on your breath, and feel those anxieties start to disappear.

20. Laugh
Laughter is one of the sillier ways to beat stress, but there's science behind it. A fit of hysterics can increase blood flow and boost immunity. Check out a hilarious YouTube video (maybe a piano-playing pug?) for a quick pick-me-up.

24. Slurp Some Honey
Drown that stress in sweetness with a spoonful of honey. Besides being a natural skin moisturizer and antibiotic, honey also provides compounds that reduce inflammation in the brain, meaning it fights depression and anxiety.

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Taking care of your long-term mental and physical

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mayoclinic.org ways to reduce or manage stress

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Stress relievers: Tips to tame stress

Stress getting to you? Try some of these tips for stress relief.
By Mayo Clinic Staff
Is stress making you angry and grouchy? Stress relievers can help bring back calm and peace to your busy life. You don't have to put a lot of time or thought into stress relievers. If your stress is getting out of control and you need quick relief, try one of these tips.

Get active

Almost any form of physical activity can act as a stress reliever. Even if you're not an athlete or you're out of shape, exercise can still be a good stress reliever.

Physical activity can pump up your feel-good endorphins and other natural neural chemicals that boost your sense of well-being. Exercise also can refocus your mind on your body's movements. This refocus can improve your mood and help the day's irritations fade away. So go on a walk, take a jog, work in your garden, clean your house, bike, swim, weight train, vacuum or do anything else that gets you active.

Eat a healthy diet

Eating a healthy diet is an important part of taking care of yourself. Aim to eat many fruits, vegetables and whole grains.

Avoid unhealthy habits

Some people may deal with stress with unhealthy habits. These may include drinking too much caffeine or alcohol, smoking, eating too much, or using illegal substances. These habits can harm your health and increase your stress levels.

Meditate

During meditation, you focus your attention and quiet the stream of jumbled thoughts that may be crowding your mind and causing stress. Meditation can give you a sense of calm, peace and balance that can help both your emotional well-being and your overall health. Meditation can empower us to enhance our well-being.

You can practice guided meditation, guided imagery, mindfulness, visualization and other forms of meditation anywhere at any time. For example, you could meditate when you're out for a walk, riding the bus to work or waiting at your health care provider's office. Try an app to show you how to do these exercises. And you can try deep breathing anywhere.

Laugh more

A good sense of humor can't cure all ailments. But it can help you feel better, even if you have to force a fake laugh through your grumpiness. When you laugh, it lightens your mental load. It also causes positive physical changes in the body. Laughter fires up and then cools down your stress response.

So read some jokes, tell some jokes, watch a comedy or hang out with your funny friends. Or give laughter yoga a try.

Connect with others

When you're stressed and irritable, you may want to isolate yourself. Instead, reach out to family and friends and make social connections. Even one good friend who listens can make a difference.

Social contact is a good stress reliever because it can offer distraction, give support, and help you put up with life's up and downs. So take a coffee break with a friend, email a relative or visit your place of worship.

Got more time? Try volunteering for a charity and help yourself while helping others.

Assert yourself

You might want to do it all, but you can't, at least not without paying a price. Learning to say no or being willing to delegate can help you manage your to-do list and your stress. Healthy boundaries are important in a wellness journey. Everyone has physical and emotional limits.

Saying yes may seem like an easy way to keep the peace, prevent conflicts and get the job done right. But instead, it may cause you inner conflict because your needs and those of your family come second. Putting yourself second can lead to stress, anger, resentment and even the wish to take revenge. And that's not a very calm and peaceful reaction. Remember, you're a priority.

Try yoga

With its series of postures and breathing exercises, yoga is a popular stress reliever. Yoga brings together physical and mental disciplines that may help you reach peace of body and mind. Yoga can help you relax and ease stress and anxiety.

Try yoga on your own or find a class - you can find classes in many areas. Hatha yoga, especially, is a good stress reliever because of its slower pace and easier movements.

Get enough sleep

Stress can cause you to have trouble falling asleep. When you have too much to do - and too much to think about - your sleep can suffer. But sleep is the time when your brain and body recharge. Most adults need about 7 to 9 hours of sleep each night.

And how well and how long you sleep can affect your mood, energy level, focus and overall functioning. If you have sleep troubles, make sure that you have a quiet, relaxing bedtime routine. For example, listen to soothing music, make sure the area you sleep in is cool, dark and quiet, put phones and tablets away, and stick to a regular schedule.

Keep a journal

Writing down your thoughts and feelings can be a good release for otherwise pent-up feelings. Don't think about what to write - let it happen. Write anything that comes to mind. No one else needs to read it. So don't aim for perfect grammar or spelling.

Let your thoughts flow on paper, or on the computer screen. Once you're done, you can toss out what you wrote or save it to think about later.

Get musical and be creative

Listening to or playing music is a good stress reliever. It can provide a mental distraction, lessen muscle tension and lower stress hormones. Turn up the volume and let your mind be absorbed by the music.

If music isn't one of your interests, turn your attention to another hobby you enjoy. For example, try gardening, sewing, reading or sketching. Or try anything that makes you focus on what you're doing rather than what you think you should be doing.

Seek counseling

If new stressors are making it hard for you to cope or if self-care measures aren't relieving your stress, you may want to think about therapy or counseling. Therapy also may be a good idea if you feel overwhelmed or trapped. You also may think about therapy if you worry a great deal, or if you have trouble carrying out daily routines or meeting duties at work, home or school.

Professional counselors or therapists can help you find the sources of your stress and learn new coping tools.

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Show references

1. How stress affects your health. American Psychological Association. http://www.apa.org/helpcenter/stress.aspx. Accessed Jan. 24, 2023.

2. Relaxation techniques: What you need to know. National Center for Complementary and Integrative Health. https:// www.nccih.nih.gov/health/relaxation-techniques-what-you-need-to-know. Accessed Jan. 23, 2023.

3. Meditation and mindfulness: What you need to know. National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/meditation-and-mindfulness-what-you-need-to-know. Accessed Jan. 23, 2023.

4. Yoga: What you need to know. National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/yoga-what-you-need-to-know. Accessed Jan. 23, 2023.

5. Stress and your health. U.S. Department of Health & Human Services. https://www.womenshealth.gov/mental-health/good-mental-health/stress-and-your-health. Accessed Jan. 23, 2023.

6. I'm so stressed out! Fact sheet. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/so-stressed-out-fact-sheet. Accessed Jan. 24, 2023.

7. Seaward BL. Essentials of Managing Stress. 5th ed. Jones & Bartlett Learning; 2021.

8. Creagan ET (expert opinion). Mayo Clinic. Feb. 8, 2023.

See more In-depth

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Stress relievers can help restore calm to your chaotic life. When stress gets out of control, try these tips for quick relief.

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clevelandclinic.org ways to reduce stress

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clevelandclinic.org ways to reduce stress

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We could all use a little less stress in our lives, am I right? Between everyday work stress to maintaining relationships, navigating social engagements and wrangling the kids stress, there's more than enough stress to go around. Luckily, there are ways to ease your stress levels if you set your mind to it.

Clinical psychologist Adam Borland, PsyD, explains how stress works and healthy ways we can help manage stress before it gets out of control.

What is stress?

Stress is your body's response to a challenge or demand. Everyone experiences stress, which can be triggered by a range of events, from small daily hassles to major changes like a divorce or job loss. The stress response includes physical components like an elevated heart rate and blood pressure, thoughts and personal beliefs about the stressful event, and emotions, including fear and anger.

"Although we often think of it as being negative, stress can also come from positive changes in your life, like getting a promotion at work or having a new baby," says Dr. Borland.

How can we handle stress in healthy ways?

Stress serves an important purpose - it enables us to respond quickly to threats and avoid danger. But lengthy exposure to stress may lead to mental health difficulties like anxiety and depression, or increased physical health problems.

"A large body of research suggests that increased stress levels interfere with your ability to deal with physical illness," says Dr. Borland. "While no one can avoid all stress, you can work to handle it in healthy ways that increase your potential to recover."

1. Eat and drink to optimize your health

Some people try to reduce stress by drinking alcohol or eating too much. These actions may seem to help in the moment, but actually may add to stress in the long run. Caffeine also can compound the effects of stress. While consuming a healthy, balanced diet can help combat stress.

2. Exercise regularly

In addition to having physical health benefits, exercise has been shown to be a powerful stress reliever. Consider noncompetitive aerobic exercise, strengthening with weights or movement activities like yoga or Tai Chi, and set reasonable goals for yourself. Aerobic exercise has been shown to release endorphins - natural substances that help you feel better and maintain a positive attitude.

3. Stop using tobacco and nicotine products

People who use nicotine often refer to it as a stress reliever. However, nicotine actually places more stress on your body by increasing physical arousal and reducing blood flow and breathing. Plus, it can worsen chronic pain, so if you're experiencing prolonged tension and body aches, smoking won't help.

4. Study and practice relaxation techniques

Taking the time to relax every day helps manage stress and protect your body from the effects of stress. You can choose from a variety of techniques, such as deep breathing, guided imagery, progressive muscle relaxation, and mindfulness meditation. Many online and smartphone apps provide guidance on these techniques. Although some require purchase costs, many are available free of charge.

5. Reduce triggers of stress

If you're like most people, your life may be filled with too many demands and too little time. For the most part, these demands are ones we've chosen. But you can free up time by practicing time-management skills like asking for help when it's appropriate, setting priorities, pacing yourself and reserving time to take care of yourself.

6. Examine your values and live by them

The more your actions reflect your beliefs, the better you'll feel, no matter how busy your life is. Use your values when choosing your activities.

"Considering the stressful demands and responsibilities we face on a daily basis, it's important to engage in activities that are in line with our values and speak to us on a personal level," encourages Dr. Borland.

7. Assert yourself

It's OK to say "no" to demands on your time and energy that'll place too much stress on you. You don't always have to meet the expectations of others.

8. Set realistic goals and expectations

It's also OK - and healthy - to realize you can't be 100% successful at everything all at once. Be mindful of the things you can control and work on accepting the things that you can't control.

9. Sell yourself to yourself

When you're feeling overwhelmed, remind yourself of what you do well. There are ways you can build a healthy sense of self-esteem.

10. Try biofeedback

This behavioral technique helps you learn stress reduction skills by providing information about muscle tension, heart rate and other vital signs as you attempt to relax. It's used to gain control over certain bodily functions that cause tension and physical pain. Biofeedback can be used to help you learn how your body responds in stressful situations, and how to cope better. If a headache, such as a migraine, begins slowly, many people can use biofeedback to stop the attack before it becomes full-blown.

If you're interested in any of these techniques, ask your healthcare provider for more information or other suggestions they may have. Often, counseling can help you recognize stress factors that may not even be readily obvious.

What to do if you have trouble sleeping

Sleep is often sacrificed when you're overwhelmed with stress. You may experience insomnia because of discomfort, stress from personal concerns, or side effects from your medications. If you can't sleep, try these tips:

Establish a regular sleep schedule: go to bed and get up at the same time every day.

Make sure your bed and surroundings are comfortable. Arrange the pillows so you can maintain a comfortable position.

Keep your bedroom dark and quiet.

Use your bedroom for sleeping only. Don't work or watch TV in your bedroom.

Avoid napping too much during the day. At the same time, remember to balance activity with periods of rest.

If you feel nervous or anxious, talk to your spouse, partner or a trusted friend. Get your troubles off your mind.

Listen to relaxing music.

Don't rely on sleeping pills. They can be harmful when taken with other medications. Use them only if recommended for a brief period by your healthcare provider if other nonmedication methods don't work.

Take diuretics, or "water pills," earlier if possible, so you don't have to get up in the middle of the night to use the bathroom.

If you can't sleep, get up and do something relaxing until you feel tired. Don't stay in bed worrying about when you're going to fall asleep.

Avoid caffeine.

Maintain a regular exercise routine, but don't exercise within two to three hours before the time you go to bed.

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We could all use a little less stress in our lives, am I right? Between everyday work stress to maintaining relationships, navigating social engagements and wrangling the kids stress, there's more than enough stress to go around. Luckily, there are ways to ease your stress levels if you set your mind to it.

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National Institute of Mental Health (NIMH)

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View the related infographic to share this information on social media.

Feeling overwhelmed? Read this fact sheet to learn whether it's stress or anxiety, and what you can do to cope.

Is it stress or anxiety?

Life can be stressful-you may feel stressed about performance at school, traumatic events (such as a pandemic, a natural disaster, or an act of violence), or a life change. Everyone feels stress from time to time.

What is stress? Stress is the physical or mental response to an external cause, such as having a lot of homework or having an illness. A stressor may be a one-time or short-term occurrence, or it can happen repeatedly over a long time.

What is anxiety? Anxiety is your body's reaction to stress and can occur even if there is no current threat.

If that anxiety doesn't go away and begins to interfere with your life, it could affect your health. You could experience problems with sleeping, or with your immune, digestive, cardiovascular, and reproductive systems. You also may be at higher risk for developing a mental illness such as an anxiety disorder or depression. Read more about anxiety disorders.
So, how do you know when to seek help?
Stress vs. Anxiety

Stress

Both Stress and Anxiety

Anxiety

Generally is a response to an external cause, such as taking a big test or arguing with a friend.

Goes away once the situation is resolved.

Can be positive or negative. For example, it may inspire you to meet a deadline, or it may cause you to lose sleep.

Both stress and anxiety can affect your mind and body. You may experience symptoms such as:

Excessive worry

Uneasiness

Tension

Headaches or body pain

High blood pressure

Loss of sleep

Generally is internal, meaning it's your reaction to stress.

Usually involves a persistent feeling of apprehension or dread that doesn't go away, and that interferes with how you live your life.

Is constant, even if there is no immediate threat.

It's important to manage your stress.

Everyone experiences stress, and sometimes that stress can feel overwhelming. You may be at risk for an anxiety disorder if it feels like you can't manage the stress and if the symptoms of your stress:

Interfere with your everyday life.

Cause you to avoid doing things.

Seem to be always present.

Coping With Stress and Anxiety

Learning what causes or triggers your stress and what coping techniques work for you can help reduce your anxiety and improve your daily life. It may take trial and error to discover what works best for you. Here are some activities you can try when you start to feel overwhelmed:

Keep a journal.

Download an app that provides relaxation exercises (such as deep breathing or visualization) or tips for practicing mindfulness, which is a psychological process of actively paying attention to the present moment.

Exercise, and make sure you are eating healthy, regular meals.

Stick to a sleep routine, and make sure you are getting enough sleep.

Avoid drinking excess caffeine such as soft drinks or coffee.

Identify and challenge your negative and unhelpful thoughts.

Reach out to your friends or family members who help you cope in a positive way.

Recognize When You Need More Help

If you are struggling to cope, or the symptoms of your stress or anxiety won't go away, it may be time to talk to a professional. Psychotherapy (also called "talk therapy") and medication are the two main treatments for anxiety, and many people benefit from a combination of the two.

If you are in immediate distress or are thinking about hurting yourself, call the National Suicide Prevention Lifeline toll-free at 1-800-273-TALK (8255). You also can text the Crisis Text Line (HELLO to 741741) or use the Lifeline Chat on the National Suicide Prevention Lifeline website.

If you or someone you know has a mental illness, is struggling emotionally, or has concerns about their mental health, there are ways to get help. Read more about getting help.

More Resources

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 20-MH-8125

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View the related infographic to share this information on social media. Feeling overwhelmed? Read this fact sheet to learn whether it's stress or anxiety, and what you can do to cope. Life can be stressful-you may feel stressed about performance at school, traumatic events (such as a pandemic, a natural disaster, or an act of violence), or a life change.

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Stress affects all systems of the body including the musculoskeletal, respiratory, cardiovascular, endocrine, gastrointestinal, nervous, and reproductive systems.

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How stress affects your body and behavior

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Learn how stress symptoms can affect your health so that you can take action.