Insomnia and the value of sleep

Chronic insomnia is a leading symptom of many chronically ill patients and one of the leading root causes of chronic fatigue. Insomnia is diagnosed when one or more of the following symptoms present: 

  • difficulty in initiating sleep
  • difficulty in maintaining sleep
  • waking too early
  • or sleep that is chronically nonrestorative or of poor 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 any of the following daytime impairments:

  • fatigue or malaise
  • attention, concentration, or memory impairment
  • social or vocational dysfunction or poor school performance
  • mood disturbance or irritability
  • daytime sleepiness
  • motivation, energy, or initiative reduction
  • proneness to error/accidents at work or while driving
  • tension, headaches, or gastrointestinal symptoms in response to sleep loss
  • 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. Except for the diagnosis of an obstructive sleep disorder such as sleep apnea, many alternative therapies can be of great assistance in restoring quality sleep.

Disruptors of Quality Sleep

Pain and Depression

Approximately 80% of untreated insomnia arises from either pain or depression. Pain as a symptom is generlly obvious to the individual, but the majority of patients with insomnia deny having any signs of depression. Insomnia is also known to increase the likelihood of developing a major depressive disorder, within a 1-year period, by a factor of four. Depression and pain can lead to insomnia and chronic insomnia can lead to depression and pain syndromes like fibromyalgia. Frequently patients can become overly fixated on insomnia and not recognize or minimize other common 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.

Stress and Neurotransmitter Imbalances

Insomnia often begins with a stressful event, such as the death of a loved one, loss of a job, chronic illness, moving, and any other physical or emotional stressor that persists beyond a few weeks or months. Often stress is multi-layered such as an onion having multiple obvious layers, with each layer(aggravator) 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. The mind seems to always be racing with thoughts of tomorrow’s tasks or today’s unfinished tasks. The bedroom itself becomes a cue to begin to think too much. Anxious patients usually have difficulty falling asleep. 

Other causes of insomnia arising from neurotransmitter studies of the brain, demonstrate physiological signs suggestive of an hyperarousal or sympathetic state noticed as increases in adrenaline or cortisol. When these neurotransmitters and hormones are elevated during the night, sleep disturbance will surely be present. Another study using MRI imaging, 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, and as such it is often prescribed in the form of prescription benzodiazepenes for stress, anxiety, and sleep disturbance. 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 frequent root causes. Naturopathic physicians may utilize natural precursor amino acids to support GABA, Serotonin, and Adrenaline to restore natural stress response and increase deep sleep.

Poor Sleep Hygeine

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, late eating, TV watching, and absence of a bedtime routine. Often children have difficulty in going to bed, or staying asleep, or just staying out late, and can disrupt healthy sleep routines for the parents. Good sleep hygiene will include habits and routines that help the body to begin at least an hour before bedtime to prepare the mind to sleep deeply. 

Sleep Apnea

Sleep apnea is often expected when someone is observed snoring or in the absence of breathing for more than 10 seconds multiple times during the night. The patient will report feeling unrested on rising even with sufficient sleep duration. Any suspicion or observation described by the patient should be evaluated by using a sleep apnea home study test. This test is done with minimal expense within the comfort of your own home and evaluated by a sleep specialist. Newer options for treatment of mild sleep apnea offer better equipment and alternatives to C-PAP’s. If it has been more than 5 years since your last sleep study and evaluation it may be useful to evaluate current need and potential of newer equipment and options.

Treatments for Improving Sleep

Cognitive Therapy Better than Drug Therapy

What treatments are recommended 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 reserved as the last option after considering the implentation of congnitive 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 cognitive therapy including techniques such as relaxation therapy, stimulus control therapy, and sleep restriction therapy. Although research is lacking in 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.

Exercise

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. There is not a drug or herb yet discovered that is able to do even near the same.

Detoxification and Intestinal Cleanses

Our observation over many years of helping patients detoxify and improve the intestinal microbiome through cleanses and anti-candida protocols indicate sleep improves. This is another example of how important it is to take a whole body approach to sleep, including protocols indicating diet changes, detox programs, candida cleansing, amino acid therapy, relaxation therapies, and exercise. This combination of therapies helps a significant number of our patients with sleep concerns within a couple of weeks. Sleep feels great and helps us manage our lives better and natural medicine provides easy and effective solutions without extravagant expense or long term drug dependence.

Neurofeedback Therapy

There is an intimate connection between insomnia and disorders of arousal such as anxiety and depression. Easily observed on a qQEEG or brain map are elevated or asymmetric brain waves in the Delta, Alpha, and Beta ranges. Neurofeedback is able to help a patient reduce these overactive or imbalanced brain wave patterns resulting in better sleep onset and maintenance. As the brain becomes more balanced, clients report improved sleep and an easier time getting up in the morning. Often one of the first signs that Neurofeedback is helping any condition is a noticeable change in dysfunctional sleeping patterns.

Frequency Specific Microcurrent

Frequenxy Specific Microcurrent therapy is an energy therapy that helps reset the nervous system. Using very specific and custom designed protocols, frequencies are directed through the nervous system and all cells of the body to calm stress and the sympathetic nervous system’s fight or flight alarms. The resposne to treament is a feeling of being relaxed with patients reporting improving sleep often with just one session.

Natural Herbs and Supplements

Sleep is so valuable and irreplaceable that if the above therapies fail to provide relief, we will begin to provide natural remedies and therapies known to reverse insomnia. Our goal is to improve sleep quality while reducing any risk or potential side effects from sleep medications. Natural herbal supplements and amino acids can often be helpful and we find a significant number of patients respond with some benefit.

Relaxation Therapy

What is relaxation therapy and how does one perform this technique? 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, 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 tension and relaxation. Because the eyes are closed, one is forced to concentrate on the sensation of tension and relaxation. Because 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.

PROGRESSIVE MUSCLE RELAXATION

For sleep improvement, perform PMR in bed. Get as comfortable as possible–no tight clothes, no shoes, don’t cross your legs. Take a deep breath; let it out slowly. Again. What you’ll be doing is alternately tensing and relaxing specific groups of muscles. After tension, a muscle will be more relaxed than prior to the tensing. Concentrate on the feel of the muscles, specifically the contrast between tension and relaxation. In time, you will recognize tension in any specific muscle and be able to reduce that tension. Don’t tense muscles other than the specific group at each step. Don’t hold your breath, grit your teeth, or squint! Breath slowly and evenly and think only about the tension-relaxation contrast. Each “tensing” is for 10 seconds; each “relaxing” is for 20 seconds. Count “one one thousand, two one thousand…” until you have a feel for the time span. Note that each step is really two steps–one cycle of tension-relaxation for each set of opposing muscles. Do the entire sequence once a day if you can, until you feel you are able to control your muscle tensions. Be careful: If you have problems with pulled muscles, broken bones, or any medical contraindication for physical activities, consult your doctor first.

BEGIN!

  1. Hands. The fists are tensed; relaxed. The fingers are extended; relaxed.
  2. Biceps and triceps. The biceps are tensed (make a muscle–but shake your hands to make sure not tensing them into a fist); relaxed (drop your arm to the bed–really drop them). The triceps are tensed (try to bend your arms the wrong way); relaxed (drop them).
  3. Shoulders. Pull them back (careful with this one); relax them. Push the shoulders forward (hunch); relax.
  4. Neck (lateral). With the shoulders straight and relaxed, the head is turned slowly to the right, as far as you can; relax. Turn to the left; relax.
  5. Neck (forward). Dig your chin into your chest; relax.
  6. Mouth. The mouth is opened as far as possible; relaxed. The lips are brought together or pursed as tightly as possible; relaxed.
  7. Tongue (extended and retracted). With mouth open, extend the tongue as far as possible; relax (let it sit in the bottom of your mouth). Bring it back in your throat as far as possible; relax.
  8. Tongue (roof and floor). Dig your tongue into the roof of your mouth; relax. Dig it into the bottom of your mouth; relax.
  9. Eyes. Open them as wide as possible (furrow your brow); relax. Close your eyes tightly (squint); relax. Make sure you completely relax the eyes, forehead, and nose after each of the tensings–this is actually a toughy.
  10. Breathing. Take as deep a breath as possible–and then take a little more; let it out and breathe normally for 15 seconds. Let all the breath in your lungs out–and then a little more; inhale and breathe normally for 15 seconds.
  11. Back. With shoulders resting against the bed, push your body forward so that your back is arched; relax. Be very careful with this one, or don’t do it at all.
  12. Butt. Tense the butt tightly and raise pelvis slightly off bed; relax. Dig buttocks into bed; relax.
  13. Thighs. Contract thighs; relax. Dig your feet (heels) into the bed; relax.
  14. Stomach. Pull in the stomach as far as possible; relax completely. Push out the stomach or tense it as if you were preparing for a punch in the gut;
  15. Calves and feet. Point the toes (without raising the legs); relax. Point the feet up as far as possible (beware of cramps-if you get them or feel them coming on, shake them loose); relax.
  16. Toes. With legs relaxed, dig your toes into the bed; relax. Bend the toes up as far as possible; relax. Now just relax for a while.

As your days of practice progress, you may wish to skip the steps that do not appear to be a problem for you. After you’ve become an expert on your tension areas (after a few weeks), you can concern yourself only with those. These exercises will not eliminate tension permanently, but when it arises, you will know it immediately, and you will be able to “tense-relax” it away or even simply wish it away. Please note that an exercise program of any sort that stresses and stretches a full range of muscles can be used in this fashion if only you pay attention to the differences between tensions and relaxations of the muscles. Yoga is particularly good, but is very demanding at first. Tai chi is also highly recommended.

GUIDED IMAGERY RELAXATION

Another technique, under the umbrella of relaxation therapy, is Guided Imagery Relaxation. This technique focuses on cognitive arousal and uses techniques of visualizing a relaxing setting or activity. Imagery can be generated from within your own thoughts or it can be guided. Guided imagery is a type of visualization relaxation where the stream of your imagery is guided by someone else – a therapist, a coach, or an downloaded app. The following are three examples of guided imagery exercises. Set aside some time when you won’t be interrupted. You can pre-record these exercises first and then listen with your eyes closed.

Imagery Exercise #1:

Pick a favorite place. It could be a garden, a waterfall, a room, or anything else. A place where you feel good and safe. Now, close your eyes and go to that favorite place. Walk around slowly and notice the colors and textures around you. What do you see? … What do you feel? … What do you hear? … What do you smell? Take your time while you walk around. Spend some time exploring each of your senses. And notice how good and relaxed you feel. Remember these sensations, they are the sensations of your very special place. A place where you can relax. Say to yourself: “I am relaxed, my body feels warm and heavy, I am safe here”. Enjoy the feeling of deep relaxation. When you are ready, gently open your eyes and come back to the present moment.

Imagery Exercise #2:

Day at the beach. Imagine – It is a beautiful sunny day…you are walking on a beach…the sky is blue…the water is crystal clear…you hear the sound of gentle waves lapping, as the light breeze caresses your skin…the white sand feels warm on your bare feet and between your toes…you are wearing flowing light clothes and breathing deeply, inhaling the smell of fresh ocean air…a sense of freedom washes over your body…you lie down and let your body sink into the warm soft sand…your are completely relaxed…you sink deeper and deeper into relaxation… When you are ready, gently open your eyes and come back to the present moment.

Imagery Exercise #3:

Imagery for tension release. Imagine an object or a color that represents stress to you. For example, you can imagine the color red, or a rope with knots, or a loud startling noise. When you have your image, say to yourself: “I release tension”. Imagine your image slowly transforming into something calming. The color red can slowly fade into a nice soft and gentle color pink. The rope with knots can slowly transform into a smooth and soft silk or velvet fabric. And the loud noise can gradually transform into a soothing sound of ocean waves. When you are done with the transformation, say to yourself: “I am relaxed”. When you are ready, gently open your eyes and come back to the present moment.

I find these techniques for relaxing to be so effective that if I am not careful I may be taking a great nap before I even notice. Remember, there are many downloadable apps that provide a recited dialogue for Progressive Muscular Relaxation and for Guided Imagery Relaxation if that will help to get started or continue in therapy. As a reminder relaxation therapy and cognitive therapy have been shown in research to be more effective in the long run than prescription medications. So give it a try and relax.