Insomnia as a chief complaint, the main reason for a patient visit, is responsible for approximately 10% of medical visits. When one considers that It’s a common add-on to visits for many other diagnoses, its importance is further underscored.
A careful history can help to glean underlying causes and hopefully help in putting together a treatment plan. It’s important, for instance, to ask whether a patient has difficulty falling asleep or whether he or she awakens frequently after falling asleep easily. Difficulty falling asleep can be easier to treat as patients with this complaint often respond to more natural treatments that re-set the body’s natural clock. Some of these might include melatonin, passionflower extract, valerian, or kava.
Laboratory tests that include a CBC, thyroid function tests, chemistry panel and hormone levels (if appropriate) are part of a standard work-up for insomnia. They will reveal electrolyte abnormalities, thyroid dysfunction, hidden infections, anemia, and peri-menopausal hormone fluctuations.
Difficulty sustaining sleep can have different implications. It’s important in this case, to rule out subclinical depression. Sleep disorders of this kind are often typical of depression. It’s important to assess whether or not this may be of a transitory nature, e.g. temporary external events that may heighten anxiety and stress levels. Additionally, if depression has been diagnosed, certain antidepressants are classic offenders in regard to altering sleep patterns. Wellbutrin, for example, can impede sleep, whereas tricyclics, such as Amitriptyline can have a marked sleep-inducing effect.
Steroids, such as Prednisone, can interrupt sleep as well as make it difficult to fall asleep. Thyroid medications such as Synthroid or Armour Thyroid can impede sleep. Oral contraceptives and hormone replacement therapy for menopause can alter sleep patterns as well as energy levels during the day.
Stimulants such as caffeine can have a profound effect on sleep patterns. Patients often wrongly assume that tolerance to a certain daily caffeine intake precludes the possibility that the caffeine may be impeding sleep. However, a profound change in sleep patterns can often be effected with a decrease or cessation of daily caffeine consumption. Caffeine is actually a bona fide mood-altering substance according to the food and drug administration.
Similarly, it is often assumed that tolerance to, and indeed craving for, nicotine suggests that a patient may be immune to its known stimulant effects. Once again, this may be an erroneous assumption. Tolerance to daily stimulant effects can be quite independent of nighttime over-stimulatory effects.
In addition to good nutrition and the judicious use of certain supplements such as passionflower, valerian, kava and melatonin, basic sleep hygiene is mandatory. Caffeine intake should be limited to at least six hours before bedtime. The patient should get into bed at the same time each night, set an alarm, and awaken at the same time each morning. This sleep schedule should be adhered to seven days a week. “Catching up” on sleep on weekends can wreak havoc on the body’s internal clock. There should not be any television or music in the bedroom. If It’s necessary to watch TV or read in order to fall back asleep, the patient should get out of bed and read, listen to music or watch TV in another room. Proper diaphragmatic breathing can do wonders to assist falling asleep. I suggest a simple course of 50 diaphragmatic breaths before falling asleep. I often teach patients in the office – where I can watch them breathe – how to properly empty the lungs, how long to exhale and how long to hold an inhalation while moving the diaphragm appropriately.
After these basics have been addressed, It’s often rewarding to look at occult food allergies as they can actually alter sleep patterns.
A Closer Look at the Herbs
Passionflower’s active component is harmine. This can inhibit the breakdown of serotonin (which can then promote sleep and balance moods). It’s odorless and tasteless extract can be added to a glass of water and consumed before falling asleep and upon awakening in the middle of the night as necessary.
Valerian is a sedative plant that also has known anti-hypertensive effects. It is more likely to induce daytime sleepiness than is passionflower.
Melatonin is an actual extract from pineal gland tissue.
Kava can be ingested in capsule form or sprayed under the tongue for faster acting sedative effects. It can also have mood-altering effects because it has a mechanism of action that’s very similar to that of a benzodiazepene drug. In fact, its concomitant use with these drugs is contraindicated.