When Insomnia Becomes A Sign For Deeper Issues (PART ONE)

We’ve all been there – those nights were you toss and turn in bed, just wishing that sleep would finally wash over you. And this starts to happen night after night, and eventually you start to just get used to it. This is just how things are going to be for you; this is your new “normal”.

However, this is your body trying to tell you something. Often times, our body sends us signals and alarm signs, and we just need to learn to listen. Chronic insomnia can be a sign for numerous different health conditions. Here are some of the things that may be influencing your sleep:

1) Adrenal dysfunction

Stress plays a huge role in almost every aspect of our lives, including digestion, mood, cognitive function, and most definitely sleep. Studies show that evening and nocturnal cortisol, the main stress hormone, are especially elevated in those who experience insomnia [1-4]. Increased activation of the hypothalamic-pituitary-adrenal (HPA) axis increases the number of nocturnal awakenings, promoting fragmented sleep [2]. Therefore, if you’re having trouble staying asleep, this may be a problem with increased HPA axis activation and subsequent cortisol secretion.

Insomnia, stress and depression are also closely linked. Chronic HPA activation puts you at greater risk for other co-morbidities such as depression and anxiety [4]. Insomnia and cognitive intrusions following stress also predict depression severity 1 and 2 years later. Those with high cognitive intrusions experiencing insomnia revealed the highest rates of depression [5]. The aging population is especially prone to insomnia (partly due to naturally decreasing melatonin production), and experience further HPA axis dysregulation for those suffering from depression as well [6].

The naturopathic approach to supporting your adrenals often involve a combination of adaptogenic herbs, lifestyle modifications to introduce healthy stress management coping techniques, dietary recommendations, and addressing any additional factors that may be interfering with your sleep and hormone production.

2) Depression, anxiety, and/or other mental health issues

Mental health is something I am very passionate about. It seems to come up time and time again in every facet of health, and is under-represented in conversation and acceptance. Sometimes the signs of depression aren’t as obvious, and it doesn’t start with low mood. Sometimes it starts with a decrease in pleasure for things you used to find enjoyable, or increasing isolation from your former activities or people you love. Insomnia and low mood can be very closely linked (as mentioned above), as often when you don’t sleep well, you don’t feel well, and vice versa. According to this 2014 study, “Individuals with insomnia reported more severe symptoms of anxiety and depression than individuals without insomnia” [7].

Psychological issues cause deep rooted insomnia that render band-aid solutions ineffective. Cognitive behavioural therapy (CBT) is an extremely effective tool that naturopathic doctors are trained in to help with mental health issues such as depression, anxiety, and obsessive-compulsive disorder. Interestingly enough, a very recent article published in January 2018 established that insomnia specific CBT (iCBT) is now a first line treatment in the most recent European and U.S. treatment guidelines (European Sleep Research Society and the American Academy of Sleep Medicine respectively) [8].

3) Inability to activate the parasympathetic nervous system (or over-activation of the sympathetic nervous system)

Alright, I’m going to do my best to explain this part of the nervous system as simply as possible. Be prepared for the word “system” to come up A LOT, and for a bunch of acronyms (because I will definitely get tired of typing the word ‘system’).

The nervous system is a communication system using electrical impulses that sends signals between the brain, spinal cord, and the rest of the body. The autonomic nervous system (ANS) is one of these communication systems, and it is responsible for bodily functions that aren’t consciously controlled, such as breathing and heart rate. The ANS is composed of the parasympathetic nervous system (PNS) and sympathetic nervous system (SNS), which are complementary and oppose one another. The PNS known as “rest and digest” while the SNS is linked with “fight or flight”. I like to think of these two as yin and yang – they create opposing reactions in different parts of the body, and one control’s the body’s response while at rest (PNS) while the other does so during a perceived threat (SNS). The one we want to focus on for sleep is the PNS.

In a day and age where we’re constantly surrounded by lights day and night, with access to vast amounts of information at the touch of our fingertips, AND with the expectation to always be “on”, sometimes it can be hard to let our body and mind know that it’s time to wind down. Too much stimulation can put our SNS into over-drive so we have difficulty getting into the rest and digest state. [Fun fact: hyperhidrosis (or excessive sweating) can be caused by the exact same mechanism!]. This often also manifests as constipation, tense muscles, and hyper-alertness.

4) Sleep apnea

This is one of the primary diagnoses that come to mind when a patient’s partner report that they snore throughout the night. It is described as abnormal breathing during sleep that results in sleep fragmentation and daytime sleepiness. The snoring comes from the absence of airflow at the nose and mouth. Often a continuous positive airway pressure (CPAP) machine is prescribed to these patients, which have been found effective. Though rigorous diagnostic criteria have not been set, this is more prevalent in males and in the obese population. [9]

This is just the first part of it! I’ve decided to turn this into a two part series, because insomnia is quite a monster to tackle. My next article will provide additional things that may be causing your insomnia, along with some lifestyle recommendations to help you get a better sleep. Stay tuned.

Keep up to date by following me on Instagram, Facebook, and Twitter (@drtangnd).

References:

1. Rodenbeck A, Huether G, Rüther E, Hajak G. (2002). Interactions between evening and nocturnal cortisol secretion and sleep parameters in patients with severe chronic primary insomnia.  Neurosci Lett. 324(2):159-63.
2. Rodenbeck A, Hajak G. (2001). Neuroendocrine dysregulation in primary insomnia.  Rev Neurol (Paris). 157(11 Pt 2):S57-61.
3. Zhang J, Lam SP, Li SX, Ma RC, Kong AP, Chan MH, Ho CS, Li AM, Wing YK. (2014). A community-based study on the association between insomnia and hypothalamic-pituitary-adrenal axis: sex and pubertal influences. J Clin Endocrinol Metab. 99(6):2277-87. doi: 10.1210/jc.2013-3728. Epub 2014 Mar 11.
4. Vgontzas AN, Bixler EO, Lin HM, Prolo P, Mastorakos G, Vela-Bueno A, Kales A, Chrousos GP. (2001). Chronic insomnia is associated with nyctohemeral activation of the hypothalamic-pituitary-adrenal axis: clinical implications.  J Clin Endocrinol Metab. 86(8):3787-94.
5. Kalmbach DA, Pillai V, Drake CL. (2018). Nocturnal insomnia symptoms and stress-induced cognitive intrusions in risk for depression: A 2-year prospective study.  PLoS One. 13(2):e0192088. doi: 10.1371/journal.pone.0192088. eCollection 2018.
6. Belvederi Murri M, Pariante C, Mondelli V, Masotti M, Atti AR, Mellacqua Z, Antonioli M, Ghio L, Menchetti M, Zanetidou S, Innamorati M, Amore M. (2014). HPA axis and aging in depression: systematic review and meta-analysis.  Psychoneuroendocrinology. 41:46-62. doi: 10.1016/j.psyneuen.2013.12.004. Epub 2013 Dec 17.
7. Mason EC, Harvey AG. (2014). Insomnia before and after treatment for anxiety and depression.  J Affect Disord. 2014 Oct;168:415-21. doi: 10.1016/j.jad.2014.07.020. Epub 2014 Jul 18.
8. Anderson KN. (2018). Insomnia and cognitive behavioural therapy-how to assess your patient and why it should be a standard part of care.  J Thorac Dis. 2018 Jan;10(Suppl 1):S94-S102. doi: 10.21037/jtd.2018.01.35.
9. Hensley M, Ray C. (2010). Sleep apnea.  Am Fam Physician. 2010 Jan 15;81(2):195.