Insomnia and sleep disturbance

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By  Dr. Jason Porter - at  February 20, 2014    

INSOMNIA AND NEUROTRANSMITTER TESTING

Disturbance in sleep patterns is the leading cause of inability to recover from acute or chronic stress. Inability to deal with or recover from stress leads to fatigue and frequently depression. In other words properly treated insomnia improves mood and energy.

If a patient has difficulty falling asleep, staying asleep, or waking unrested, specific neurotransmitter lab tests can help determine the best natural treatment approach. In our mesa office we regularly have patients present to do testing to determine levels of norepinephrine, epinephrine, dopamine, serotonin, and tryptophan. These are standard labs run through Sonora Quest or LabCorp and are covered by most insurance plans.

The best news is that knowing these levels of neurotransmitters help determine the depth of deep sleep and its effects on how a patient handles stress. For example, if a patient has difficulty turning the mind off at the end of the day, or they find themselves feeling exhausted or overwhelmed by stress, we can see this in the lab work and modify stress expression to improve sleep patterns in the brain. Measurement of neurotransmitters allows alternative doctors to measure indirectly each patient’s individual response to stress. In fact, we could say that stress in general is the first and greatest cause in sleep disruption. Now we can test the effects of stress on the individuals themselves and on sleep patterns.

With this information, a naturopathic physician can begin to create a protocol that is individual and specific to that patient to help them handle and recover from stress and begin to sleep deeply. Often this approach to sleep concerns leads to improvement in energy and ability in handling daily stress. Neurotransmitter testing represents the best way to measure individual stress response and its overall effects on energy and sleep patterns.

DO I HAVE ONE of the NINE COMMON SYMPTOMS of INSOMNIA?

Insomnia in any patient will present with one or more of the following symptoms: difficulty in initiating sleep, difficulty in maintaining sleep, waking up too early, or sleep that is chronically nonrestorative or poor in quality. These symptoms persist even though there is adequate opportunity to sleep. Although insomnia is experienced by nearly everyone at some point in time, if symptoms persist longer than a month, insomnia often results in the following daytime impairments: 1.) fatigue or malaise 2.) attention, concentration, or memory impairment 3.) social or vocational dysfunction or poor school performance 4.) mood disturbance or irritability 5.) daytime sleepiness 6.) motivation, energy, or initiative reduction 7.) proneness to error/accidents at work or while driving 8.) tension, headaches, or gastrointestinal symptoms in response to sleep loss 9.) concerns or worries about sleep.

Of course these symptoms are common to many diseases, but any observation in disturbance of sleep must be evaluated and properly treated. Excepting for the diagnosis of an obstructive sleep disorder such as sleep apnea, many alternative therapies can be of great assistance in restoring quality sleep.

AM I AT RISK FOR INSOMNIA?

As much as 50% of the general population experiences insomnia at least a few nights in any given year. But only 15% of the population has enough impaired sleep to lead to some type of daily symptom such as fatigue, irritability, loss of concentration or motivation, and many others. Those most at risk for developing insomnia include older age, female gender, depressive disorder, substance abuse, shift worker, and unemployment.

Interestingly enough, the most common cause of insomnia is due to or associated with depression. It is difficult to say which comes first, but 80% of patients with depression or chronic pain disorders have insomnia. A good question for us to evaluate is, does lack of good restorative sleep cause depression or pain disorders like fibromyalgia, or do the conditions that cause sleep disturbance, lead to an increase in exacerbation of all symptoms? I don’t know that it really matters to know for sure which one came first, since alternative medicine can provide natural therapies to relieve every symptom no matter the original source. The synergistic approach, as found in natural medicine, to treat insomnia will produce much faster results than any singular therapy targeting just pain or sleep or even depression.

Sleep disorders are serious health concerns, which increase the likelihood of developing a major depressive disorder, within a 1-year period, by a factor of four. Whether you have had a sleep study or not, natural medicine can view the totality of symptoms and provide relief without prescribing dangerous and potentially addictive medications.

Other clues to the cause of insomnia include some studies showing physiological signs suggestive of an hyperarousal or sympathetic state. One recent MRI study found a global reduction in gamma-aminobutyric acid (GABA) amongst subjects with insomnia compared to controls. GABA is generally a very strong inhibitory or sedating neurotransmitter. These and many other studies point to chronic stress and its underlying changes in elevations of adrenaline, and eventually depletion of noradrenaline and even GABA as root causes.

STRESS LINKED TO INSOMNIA

Insomnia often begins with a stressful event, such as the death of loved one, loss of a job, chronic illness, moving, and any other physical or emotional stressor that continues to be a stressor over time in some form or fashion. Often stress is multi-layered such as an onion having multiple obvious layers, each layer having to be peeled away to eventually get to the root or initial cause of the insomnia.

Some patients with insomnia find it difficult to turn off their minds. It is always racing with thoughts of tomorrows tasks or todays offenses.. The bedroom itself becomes a cue to begin to think too much. These patients sleep better in novel or new environments. Yet the most common presentation of a patient with sleep disorder is one with depression. Patients can become overly fixated on the insomnia and not recognize or minimize their other symptoms of depression. Depression, especially in older patients, causes sleep disturbance characterized, by the inability to stay asleep and by waking early. Younger patients with depression, may have more difficulty with falling asleep. Anxiety patients usually has difficulty in falling asleep.

In addition, many of us have very poor sleep hygiene. We do things which stimulate the mind and body, not allowing ourselves to relax and wind down near the end of the day. Too much caffeine, alcohol, exercise, napping during the day, working or doing projects in bed, OTC use, late eating, TV watching, and absence of a bedtime routines. Sometimes children have difficulty in going to bed or staying asleep.

One of the only conditions that is difficult to treat with natural medicine of course is an obstructive sleep disorder, such as sleep apnea, which requires a CPAP(other treatment options do exist). We have found at the East Valley Naturopathic Medical office, that low dose melatonin is extremely helpful in down regulation over stimulated or high strung children, particularly ones who refuse a normal bedtime. Melatonin is completely natural and side effect free. The understanding  of what causes sleep disorders is extremely varied. Although there is not a lot of evidence for natural medicine present in studies, most patients with sleep disorders improve quickly on natural alternatives without the use of strong or potentially addictive hypnotics.

NATURAL RECOMMENDATIONS for INSOMNIA

So often it appears that the most common course of treatment is the use of prescription medication such as Ambien, Restoril, or Lorazepam etc; The research that has been done actually suggests that this approach should be preserved as the last option after considering the implementation of cognitive and behavioral therapy. Alternative medicine has in addition, numerous natural and safe options for inducing better sleep, without any side effects or abuse potential. In essence drug therapies should be more often the third line of therapy, instead of the current first position they seem to hold.

Studies have shown cognitive and behavioral treatments are safe and effective for sleep onset, sleep maintenance, and sleep restfulness concerns. In fact, behavioral treatment is equal to or better than results from pharmacotherapy. Current guidelines for treatment of insomnia recommend that cognitive and behavioral therapy be utilized as initial treatment. Cognitive therapy is aimed at changing a patient’s belief and attitudes about insomnia. It strives to reconstruct cognitive pathways with positive and appropriate concepts about sleep and its effects. Sometimes behavioral therapy is combined with the cognitive therapy including techniques such as relaxation therapy, stimulus control therapy, and sleep restriction therapy.

WHAT IS RELAXATION THERAPY

Relaxation therapy describes all techniques used to counter stress, anxiety, or sympathetic arousal. Two such techniques widely used include progressive muscle relaxation(PMR) and guided imagery relaxation. PMR is a technique for reducing anxiety or improving insomnia, by alternately tensing and relaxing the muscles. It was developed by American physician Edmund Jacobson in the early 1920s. Jacobson argued that since muscle tension accompanies anxiety, one can reduce anxiety by learning how to relax the muscular tension. PMR entails a physical and mental component.

The physical component involves the tensing and relaxing of muscle groups over the legs, abdomen, chest, arms and face. With the eyes closed and in a sequential pattern, a tension in a given muscle group is purposefully done for approximately 10 seconds and then released for 20 seconds before continuing with the next muscle group.

The mental component focuses on the difference between the feelings of the tension and relaxation. Because the eyes are closed, one is forced to concentrate on the sensation of tension and relaxation. Because of the feelings of warmth and heaviness are felt in the relaxed muscle after it is tensed, a mental relaxation is felt as a result. With practice, a patient learns how to effectively relax and deter anxiety and improve sleep onset and sleep maintenance.

Although research is lacking on complete effectiveness, sleep hygiene can also be added to the treatment protocol. The strongest argument for the use of cognitive and behavioral therapy indicates that this form of treatment, when compared to the individual use or combined use with prescription medication, outperforms the drugs over the long run. Meaning it produces the same or better results, and continues to sustain over time, when the drug regimes fail to maintain improvement in insomnia symptoms, once removed as a daily therapy.

Recent studies are showing increased risk of cancer associated with the use of sleep medications. One theory suggests that sleep medication, although allowing patients to fall asleep and stay asleep, may not induce deeper states of sleep which allow a patient to recover from the stress of the previous day. Lack of deep sleep leads to disease and emotional imbalance.

One of the more exciting and recent studies on lifestyle and sleep includes a recent study done comparing exercise timing and effects on sleep. What these researchers found was that patients who exercise in the morning improve REM sleep 75% compared to those who exercise in the afternoon or evening.

Our experience also at our mesa clinic is that when patients detoxify or participate in a candida diet and cleanse, sleep improves.

So we take a whole body approach to sleep including in our protocol diet, detox, candida cleansing, amino acid therapy, relaxation therapies, and exercise. This combination of therapies helps more than 95% of our patients with sleep concerns within just a few days to a couple of weeks. Sleep feels great and helps us manage our lives better with natural medicine providing easy and effective solutions, without extravagant expense or long term drug dependence.

Visit our BLOG for descriptions on how to do Progressive Muscle Relaxation and Guided Imagery Relaxation

Dr. Jason Porter

Dr. Jason Porter

Dr. Porter is a graduate of the Southwest College of Naturopathic Medicine in Arizona, and a member of the American Association of Naturopathic Physicians (AANP), the Arizona Naturopathic Medical Association (AzNMA), the Naturopathic Association of Therapeutic Injection (NATI), and the American College for the Advancement of Medicine (ACAM) where he is certified in chelation therapy. Dr. Porter is also a supervising physician at Southwest College of Naturopathic Medicine where he teaches Naturopathic Medical Students methods for treatment of chronic pain conditions and disease prevention for longevity and improvement in quality of life.

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