Friday, September 23, 2016
Wednesday, February 24, 2016
Can’t sleep? Does your frustration build as you wake up several times a night? Or do you have trouble falling asleep only to wake up an hour before your alarm goes off and then have to push through your day drinking caffeine because you can’t stay awake?
These are the cardinal symptoms of insomnia. If you answered yes to any one of these questions, and you have excessive daytime sleepiness, then you likely have insomnia. You are not alone in this struggle as insomnia and other disorders of sleep are some of the most common to affect our society and the quality of life of Americans.
Insomnia is estimated to disturb upwards of 50% of the adult population on occasion and 30% on a consistent basis. Other sleep disorders separate from insomnia such as restless leg syndrome, a miserable condition where an individual has a deep sensation of needing to move their legs as they rest in the evening while sitting or lying down, also plagues upwards of 10% of adults. Due to the misery caused by these problems, people go to their doctors in hope of effective solutions, or in an attempt to pursue a more “natural route” frequent vitamin stores seeking answers and end up taking valerian root, melatonin, and sleep time teas to aid them in getting a better night’s rest.
From a clinician’s perspective a diagnosis of insomnia cannot be immediately assumed when evaluating patients who cannot sleep, stay asleep, wake up too early, and are fatigued all day. A detailed history of sleep habits, patterns, and behaviors conbined with a detailed neurological examination are paramount to uncover the cause of the problem. Other non-insomnia related conditions also disturb rest and must be ruled out as being different from true insomnia, with sleep apnea being one of the most critical conditions to assess as it can place undue stress on the heart leading to shortening of one’s lifespan. The common solution for sleep apnea is different from insomnia and is to wear a mask that maintains airway pressure, so that stress is taken off of the heart. It is important for you to understand what your doctor has to rule out when you complain of lack of sleep as different causes require different solutions. So assuming that you do not have sleep apnea or restless leg syndrome, what is causing you to not be able to get adequate rest?
It is well documented in professional textbooks and peer reviewed journal articles that patients who cannot sleep frequently relay to their doctors that life is stressful. Because of this scientists have investigated the associations between the disorder of insomnia and the disorder of anxiety as well as the disorder of depression. Surprisingly, these associations have not been found to be meaningful to evaluating and treating insomnia. The one common denominator that was seen with insomniacs is what is termed “excessive night time worry.” The questions for the astute historian then become “are you a worrier, what are you worrying about, and why can’t you stop worrying?”
The fear center in the brain is a structure called the amygdala. Our brains have a fear center for good reason. This fear center structure helps us to identify danger, and thus to create an advantageous response to danger. The classic example of this response with which most of us are familiar being to either fight or run from a dangerous situation such as encountering a mountain lion while hiking in the Sierra’s. This reaction is known as the fight flight response. Most of us are not having the experience of stumbling across a mountain lion on a daily basis, but the fear center for insomniacs is for all intents and purposes is like an engine running at 9000 RPM’s.
Scientific studies have shown the amygdala to be critically involved with insomnia. Interestingly, it is involved with insomnia but in a different fashion in patients who have depression and yet even slightly differently in those who have anxiety disorders. In reviewing sleep statistics, upwards of 30% of the American population will suffer with anxiety disorders, 16% will have depression, and 30-50% will suffer with insomnia at times or consistently. As you can see, the amygdala is the problem for a lot of people.
Medical Doctors have been aware of this over activated amygdala, and due to this and patients frequently complaining of high levels of daily stress, patients are prescribed drugs such as Xanax to help them achieve more adequate rest. While this often helps, with routine use of drugs of this class (referred to as the benzodiazepines) other stages of non REM sleep were observed to be “fractured” by this type of approach and patients still reported being tired during the day. Therefore, other drugs such as Ambien that did not “fracture” sleep like other benzodiazepines were observed to do became commonly employed. Yet, even with the efficacy of drugs such as Ambien, many patients coming to our clinic simply do not want to be dependent on sleep medications, and are seeking an alternative solution. Unfortunately, often they have already tried the valerian root, sleepy time tea, GABA supplements, and melatonin to no avail for their problem.
This is where understanding brain chemistry and brain functionality become incredibly important to the insomniac. There are reasons for an amygdala (the fear center) being “out of control,” and to treat this condition effectively you need to know what they are. An individual’s current stressful circumstances have to be evaluated. If a patient is in one of the many of the accepted major life stressors, they may need to be referred for counseling, a psychiatric work up, or hypnotherapy. In addition, frequently patients whom we evaluate for insomnia have often experienced very serious stressful circumstances earlier in life which set the stage for them to to experience their present pattern of “excessive worry.” For example, early childhood trauma can cause the brain to create plasticity (become stronger) in the pathways associated with fear that do involve the amygdala. Translation-the early childhood trauma causes your fear center to learn fear and experience fear when there is nothing present to fear in your current life situation.
Through a comprehensive neurological examination, other areas of the brain involved with shutting off the amygdala must be assessed for their integrity and ability to shut off the constantly over firing amygdala. The critically involved areas of the brain to be assessed are the specific areas of the frontal lobes and the entire region of the memory area of the brain (the hippocampus). By ascertaining the functionality of these neurological structures, the clinician can better evaluate and assess the tug of war occurring between the involved areas of the frontal lobes and those of the memory area, and ultimately determine how they are faring in shutting off the amygdala. In addition to ascertaining this functional data, a detailed history must be obtained to account for the factors in one’s physiology which may be not allowing the frontal lobes or the memory area to do their appropriate job in calming down the amygdala. These physiological contributors include but are not limited to sex hormones, inflammation, obesity, gut bacteria, B vitamins, and cortisol whose pathways have been compromised and are negatively affecting the aforementioned brain function.
Once all of these parameters are evaluated only then can a plan be constructed and executed to nullify or calm down the metabolic elements affecting the frontal lobes and memory area. Then neuroplasticity based exercises can be effectively employed to improve function of these areas of the brain. Ultimately with this data at hand most of these processes can be addressed with natural products that can be used to calm down the overactive amygdala. Thus insomnia is frequently many complex vicious cycles that must be recognized and unwound. Once all of the variables in that person’s unique case have been assessed and targeted and properly treated, a better nights sleep with improved daytime energy then become possible.