Stress is highly prevalent in our population today and is very likely to impact sleep.¹

Stress is a well-known cause of insomnia, but the aetiology of insomnia may be more complex than we think. Individuals with insomnia are often found to have a disruption in the hypothalamic-pituitary-adrenal (HPA) axis, which will show up as a dysregulated cortisol pattern with higher evening and nocturnal levels compared to healthy sleepers,² which may lead to difficulty in initiating or maintaining sleep.

In an emerging field of research, persons who are rapidly sleep compromised when stressed may have “pathogenic sleep reactivity”, whilst those with low sleep reactivity appear generally unimpacted during stressful times. Findings suggest that ongoing exposure to stress and insomnia can cause changes in epigenetically-controlled sleep sensitivity and that this sensitisation is not always reversed after insomnia remission. Further, a blunted cortisol response during stress may explain why good sleepers exhibit higher parasympathetic activity without hyperarousal at night, causing low sleep reactivity.¹

A final component of insomnia is nonrestorative sleep (NRS), which is a distortion of the sleep architecture where the person is not spending appropriate amounts of time in the various sleep stages. This may occur without difficulty initiating or maintaining sleep.³ This can lead to depression and is also one of the key symptoms of chronic fatigue syndrome (CFS).^4,5

Whilst we see a lot of women in clinic, who seek help for stress and its influence on sleep, this case study is aiming to discuss how stress and the lack of sleep can impact the men in our society. Men aged 32 to 60 years old have been found to be significantly more stressed than men over 60, and social isolation and lack of friendships is one of the key drivers.^6,7 Men’s stress really starts to become discernible during the early stages of fatherhood as they often become socially isolated during this period.^8,9 Many men diagnosed with CFS have found the diagnosis difficult to accept, as being tired and not being able to keep up is seen as un-masculine.¹⁰

Patient history

A 45-year-old man presented in clinic with debilitating fatigue. He explained that he was experiencing exceptional life stressors, with a high-pressure job where new regulations meant he suddenly had to gain a Master’s degree to maintain his current employment. The trigger event to his stress was his beloved father’s suicide four years prior, after which he had spent two years in “panic-grieving” and felt like he had just survived for the following two. He had been to a counsellor to work through the rawest grief.  

Initial consultation:

He was able to achieve 7 hours of undisturbed sleep most nights, but would wake up exhausted at 6 am. Wanted to have 10 hours per night, but rarely achieved this.

• He felt dysfunctional on waking, with energy level at 4/10. He described himself as a light sleeper who would wake up from noises but return to sleep very easily.
• The previous 12 months he had felt as if he had “burnt-out” and was worried what would happen to his family if he couldn’t cope.
• After a regular workday he would have 3/10 energy and felt unable to engage with his wife and kids in the evening.
• He felt no joy from his regular hobbies such as fishing and soccer training, and had to force himself to participate. He would feel utterly overwhelmed after a normal weekend day with his friends. Therefore, he seldom participated and felt isolated, and knew this contributed to his low moods.
• His ability to regulate was completely gone and he felt like there was no buffer left to catch him if he fell.
• The black dog was a regular visitor, and he knew he was depressed.
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In addition, he had a draining muscle inflammation making him hobble the days after exercise.

• His feet were always tender and the middle two toes on both his feet would regularly curl up in cramps.
• All the joints in his body were described as sore, with him identifying this as slowly increasing over the last 2 years.
• In the last 3 months his physical discomfort had intensified as he now experienced restless legs when trying to sleep. The only time he was comfortable was in a hot bath.

He had no appetite in the morning as he would be gagging from the thought of his stressful workday ahead.

• He had never been able to process fatty foods and mostly avoided them.
• Easily became hungover when drinking alcohol.
• Bristol Stool Chart 6-7 from spicy and fatty foods, which he has once per week.
  • This has been his normal as long as he can remember.
• Diet for the rest of the day was limited to leftovers, nuts and seeds, and a home-cooked meal in the evening, with meat and three vegetables.

Previous medical history included atrial fibrillation three years ago, for which he had been given beta blockers for one month. Arterial flutter sometimes returns, but not frequently.

Prescription:

The aim was to restore his energy levels and reduce his sympathetic overwhelm. We also wanted to support his HPA axis, improve his cortisol in the morning but regulate it overall, whilst also supporting his heart health.

• Magnesium Powder, 9.36 g daily; containing total magnesium 350 mg, taurine 3 g, glutamine 500 mg, ascorbic acid 623 mg, total zinc 15 mg, and activated B vitamins.
• Liquid Herbal Blend for digestion, 6 drops before meals in water; containing Zingiber officinale (Ginger) 25 mL and Gentiana lutea (Gentian) 25 mL
• Liquid Herbal Blend for stress, 7.5 mL twice daily; containing Rehmannia glutinosa (Rehmannia), Bacopa monnieri (Bacopa), Scutellaria lateriflora (Skullcap), Withania somnifera (Withania) and Centella asiatica (Gotu Kola).

Lifestyle instructions:

1. Reduce blue light exposure at night before bedtime and create a better bed-time routine to allow your body to enter rest and digest before getting into bed.¹¹
   1. This will allow your body to relax and improve your time in REM sleep which will improve your sleep quality. It will also reduce occurrence of restless legs.¹²
2. Don’t try to improve too many things at once, your energy will be a finite resource for some months before we can slowly support your body back to a more normal energy pattern.
   1. If you overdo activities at this stage, you are likely to feel like you have entered overwhelm again and taken steps back in your recovery.¹⁰

Dietary changes:

1. Improve dietary intake slowly as your body will allow it, using the bitter herbs to stimulate appetite, and improve digestion.
   1. Ensure you have some protein, good fats and fibre in the morning to create sustainable energy for your stressful workday.¹³

Follow Up – 4 Weeks

Client reported good compliance and could slowly see improvements in his energy through the day. Appetite in the morning was still low most days, but on the weekends he could now enjoy breakfast with the kids.

• The biggest change had been his ability to engage with his family again and feel like he was not just grumpy and tired all the time.
• He could get up in the mornings and be able to interact with the rest of the household before going off to work.

With the increase in energy, he had also been able to return to his hobbies and his social life was improving. This means he wasn’t feeling so isolated anymore and was starting to enjoy his life again.

• He would still be overwhelmed if he took on too many activities in one weekend, but he was starting to see the light at the end of the tunnel.
• Overall, he was starting to recover some quality of life and was feeling optimistic for the first time in a couple of years.

Clinical Thoughts

Whilst both men and women struggle today with the stress and pressures or balancing careers and family, there is still an additional mental threshold for men to jump before they can seek help and recover their health. They are seen by society, and in interactions with each other, as weak if they complain about fatigue and are programmed to keep going regardless of how they really feel.

This client’s main concern was the impact of his own lack of wellbeing on his family and the safety of their future. The thought of what would become of them if he couldn’t get out of bed one day was ultimately the driving force behind his motivation to seek help. It wasn’t until he was sitting in my clinic that he realised what a complete mess his health had really become since the days when he was a young man and could literally do anything from climb a mountain to run a marathon.

The challenge with male clients as I see it in clinic is to motivate them to return after they have begun to feel better. I often see them two to three times in the initial period of their recovery, during which they have amazing progress in their quality of life and overall well-being. This client ended up coming back two years later, almost in the same state as he was at his initial appointment. He saw me a couple of times again and has not returned for any further follow-ups.

References

1. Kalmbach DA, Anderson JR, Drake CL (2018) The impact of stress on sleep: Pathogenic sleep reactivity as a vulnerability to insomnia and circadian disorders. J Sleep Res 27:e12710

2. Drake CL, Cheng P, Almeida DM, Roth T (2017) Familial risk for insomnia is associated with abnormal cortisol response to stress. Sleep. https://doi.org/10.1093/SLEEP/ZSX143

3. Roth T, Zammit G, Lankford A, Mayleben D, Stern T, Pitman V, Clark D, Werth JL (2010) Nonrestorative Sleep as a Distinct Component of Insomnia. Sleep 33:449

4. Mohamed AZ, Andersen T, Radovic S, Del Fante P, Kwiatek R, Calhoun V, Bhuta S, Hermens DF, Lagopoulos J, Shan ZY (2023) Objective sleep measures in chronic fatigue syndrome patients: A systematic review and meta-analysis. Sleep Med Rev. https://doi.org/10.1016/J.SMRV.2023.101771

5. Saitoh K, Yoshiike T, Kaneko Y, et al (2022) Associations of nonrestorative sleep and insomnia symptoms with incident depressive symptoms over 1-2 years: Longitudinal results from the Hispanic Community Health Study/Study of Latinos and Sueño Ancillary Study. Depress Anxiety 39:419–428

6. Lopuszanska-Dawid M, Kupis P, Lipowicz A, Kołodziej H, Szklarska A (2022) How Stress Is Related to Age, Education, Physical Activity, Body Mass Index, and Body Fat Percentage in Adult Polish Men? Int J Environ Res Public Health. https://doi.org/10.3390/IJERPH191912149

7. Mansour K, Greenwood CJ, Francis LM, Smith I, Olsson CA, Macdonald JA (2024) Social network investment of men: Cross-sectional and longitudinal associations with mental health problems. Appl Psychol Health Well Being 16:138–157

8. Skreden M, Skari H, Malt UF, Pripp AH, Björk MD, Faugli A, Emblem R (2012) Parenting stress and emotional wellbeing in mothers and fathers of preschool children. Scand J Public Health 40:596–604

9. Philpott LF, Leahy-Warren P, FitzGerald S, Savage E (2017) Stress in fathers in the perinatal period: A systematic review. Midwifery 55:113–127

10. Snell GE, Seage CH, Mercer J (2024) A phenomenological study on the lived experience of men with Chronic Fatigue Syndrome. J Health Psychol 29:225–237

11. Rabiei M, Masoumi SJ, Haghani M, Nematolahi S, Rabiei R, Mortazavi SMJ (2024) Do blue light filter applications improve sleep outcomes? A study of smartphone users’ sleep quality in an observational setting. Electromagn Biol Med 43:107–116

12. Fink AM, Bronas UG, Calik MW (2018) Autonomic regulation during sleep and wakefulness: a review with implications for defining the pathophysiology of neurological disorders. Clin Auton Res 28:509

13. Carreiro AL, Dhillon J, Gordon S, Higgins KA, Jacobs AG, McArthur BM, Redan BW, Rivera RL, Schmidt LR, Mattes RD (2016) The macronutrients, appetite and energy intake. Annu Rev Nutr 36:73