“50 SHADES” OF SLEEPLESS NIGHT
Chronic insomnia- Causes and solutions
Being sleep deprived for prolonged periods dramatically increases the risk of developing some serious chronic diseases. Having just one hour less sleep per night increases the expression of genes linked to inflammation, diabetes type 2, cancer, immune problems and stress. It also increases blood pressure, dysregulates hunger hormones and alters blood sugar levels.
Lack of sleep (insomnia) has reached the public health epidemic in all developed counties including South Africa. 1 in 3 people are insomniacs and according to a new study by the University of Pennsylvania School of Medicine, the prevalence of acute insomnia is 25%! It is characterised by “difficulty falling asleep or staying asleep for as little as three nights per week for at least two consecutive weeks up to three months.” Insomnia is considered chronic when it occurs at least three nights a week for more than three months and its prevalence is 75%.Adults (age 18-64) need 7-9 h of sleep, seniors (age 64 and more) 7-8 h, while teenagers need 8-10h of sleep.
Our body has a natural sleep –wake cycle that should be strictly respected. In fact, our body contains a range of body clocks that regulate everything from metabolism to psychological functioning. These clocks run in every single cell in our body as discovered by three scientists who won the Nobel Prize for Medicine (2017) for their work on Circadian Rhythms. Keeping these clocks synchronised is important for to maintaining functions such as behaviour, sleep, hormonal activity, body temperature, fat metabolism etc. In simple terms, we need to sleep when our body is designed to sleep and eat when our natural body rhythm says so!
When we distress this circadian rhythm by not getting enough sleep over a period of time, it results in huge deraignments through our metabolic system, often causing chronic diseases. Doctors and patients usually underestimate these causes, paying attention only to immediate symptoms occurring after sleepless nights such as tiredness, irritability, and grogginess. But the impact of chronic insomnia is much more profound and can lead to severe unfavourable outcomes:
- Increased risk of Type 2 diabetes
- Increased weight gain and risk of obesity
- Higher incidence of cancer
- Higher incidence of high blood pressure and cardiovascular disease
- Increased risk of osteoporosis
- Increased risk of neurological problems -dementia and Alzheimer’s disease
- Increased risk of stomach ulcers and GIT problems
- Reduced immune response
- Increase premature aging by affecting growth hormone production and cortisol alteration (HPA axis)
- Reduced ability to learn affecting study and school performance
- Reduced creativity and productivity at work
- Slow down reaction time, increased work injuries and road accidents.
It was disturbing to find out that the majority of motor vehicle accidents are a consequence of chronic insomnia, the figures being much higher than for accidents due to drunk driving and texting while driving.
One interesting animal study indicates that continuous exposure to light may be associated with increases in male hormone production (androgens). And as a result poor sleep habits may be an important contributing factor in the development of PCOS.
What can cause insomnia:
1. Disruption of Circadian rhythms – This usually happens to shift workers and travellers frequently crossing time zones. But nowadays these rhythm disturbances are caused by poor sleep hygiene, erratic sleep schedules, staying up late at night on computers and cellphones and not allowing the sleep-wake cycle to take its natural sequence. With the ongoing disruption of synchronised work of our body clocks, irreversible damage can be done to the master clock in the brain leading to serious insomnia that is difficult to fix.
2. Affected Melatonin production- Daily melatonin circadian rhythm is strongly tied to the 24-hour cycle of light and dark, with its levels rising around 9 p.m., and peaking during midnight hours, falling to very low levels just before dawn and staying low throughout the day.Similar to other hormones melatonin also declines with age, and that is one of the reasons why older people often have interrupted sleep patterns. But there is an increasing melatonin decline being seen in younger populations. The blue light emitted by screen technology (computer, cell phones, smart TVs) significantly inhibits melatonin production, making it difficult to fall asleep and stay asleep through the night. Electromagnetic fields (EMFs) from these technologies also have substantial effects on melatonin production. Using these technologies and bright lighting prior to bedtime mitigates the peak of melatonin (affecting its circadian rhythms) which dramatically change a sleeping pattern. Even with eyes closed during sleep if our cell phones are not switched off or we fall asleep with a TV on, their emitting light can continue affecting melatonin as the retina can still detect the light. How detrimental is this for anyone including children and teenagers that are now also suffering from insomnia!
3. Chronically elevated levels of night Cortisol– Prolonged hyperactivity of the adrenal glands (HPA axis) and increased production of cortisol opposes melatonin activity and contributes to chronic insomnia. Typically, this happens during times of persistent stress. This is easily detected by salivary or urinary cortisol testing. High night time cortisol levels also affect the “master clock” in the brain and often results in depression coexistent to insomnia. Vitamin B6, and B5 and vitamin C often become depleted with prolonged hyperactivity of the adrenal glands and chronically increased cortisol, perpetuating this problem further. Furthermore, the cortisol feedback mechanisms are dependent on adequate amounts of calcium, magnesium, potassium, manganese, and zinc and depletion of these minerals during chronic stress prevents successful treatment of high cortisol and insomnia unless corrected. Magnesium is critical as it also regulates the production of cortisol and prevents the uptake of cortisol into the brain.
In summary, adrenal (HPA axis) hyperactivity can have a negative impact on sleep, decreasing deep slow-wave sleep, and resulting in shortened sleep time. Consequently, sleep problems and can further add to HPA axis dysfunction and keep cortisol high.
4. Estrogen and Progesterone altered levels– Both estrogen and progesterone have a direct effect on the sleep centre in the brain and the master clock. These hormones also affect the levels of an important calming neurotransmitter- GABA. Progesterone deficiency is very common, even in the younger generations, due to chronic stress during which the precursor for progesterone production is” stolen” by cortisol. Progesterone promotes sleep because it makes a metabolite called ALLO which interacts with GABA receptors and when deficient cause fewer restorative sleep cycles. During menopause, at the time of prolonged stress and in women on the hormonal birth control pill, insomnia could become really unbearable due to the lack of progesterone. For these conditions putting patients on sleeping tablets or randomly treating with melatonin will not relieve insomnia as they actually need progesterone. Estrogen dominance (excessive estrogen) that can happen at any age and gender (including males!) can cause insomnia. Estrogen excess causes a feeling of tension, irritability, and trouble falling asleep. Estrogen deficiency causes difficulty in staying asleep, and many menopausal women report waking at 2 am as the single most troubling symptom of menopause. Putting these women on bio-identical hormones radically reduce insomnia.
5. GABA/glutamate alliterate ratio– Glutamate and GABA oppose each other’s activity in the brain and promoting GABA activity can increase the “calming effect” and facilitate better sleeping. Decreasing glutamate activity will also support healthy HPA axis (cortisol production) function that is also affecting sleep. GABA/glutamate alliterate ratio is often seen in Fibromyalgia patients who usually suffer from chronic insomnia. It is not easy to promote GABA activity if Glutamate levels are high. To address elevated glutamate, evaluation of leaky gut, food sensitivities and allergies, and infections needs to be considered. Sometimes just adding L-theanine and NAC can decrease glutamate and promote sleep. But this needs to be done under doctors supervision.
Unbalanced methylation ( COMT positive gene), bruxism, sleep apnea, restless leg syndrome, sleepwalking, narcolepsy, some chronic medication’s side effect, can also be present as a single cause of insomnia that need to be investigated by integrative physicians.
Conventional medical doctors intend to treat all insomnias with various sleeping tablets. Integrative physicians are dedicated to investigating, finding and treating the cause of insomnia. They also initiate and teach patients about the importance of prioritising sleeping hygiene every night that needs to be applied together with target interventions. All patients suffering from the chronic lack of sleep need to understand that chronic insomnia leads to detrimental diseases and they don’t need to feel hopeless about resolving it.
References for this article are available on request.