Shining the Light on Insomnia's Hyperarousal
Overview
For the 60 million Americans struggling with insomnia1, it can be disheartening to hear that rather than having a direct causative factor that can be medically treated, insomnia is more largely related to lifestyle dynamics than anything else.1
Understanding the etiology of insomnia can best be related to considering perpetuating factors. These could include dependence on daytime stimulants, illnesses that come with nocturnal pain or waking, circadian rhythm disorders and stressful events.2 Physiologically and in comparison to controls, poor sleepers have notable differences including an elevated core body temperature, increased nighttime cortisol and elevated heart rates.1,3 This apparent hyperarousal has awakened new theses on a potential nocturnal sympathetic activation, 1 stating that poor sleepers have a persistent trait arousal that is incompatible with restorative sleep.2 The ability to work longer and stay up later due to advances in technology despite harmful effects of over- light exposure4 certainly contributes to hyperarousal and maladaptive sleep.
Sleep loss has also been linked to blood sugar dysregulation, immune function, and elevations in inflammation. One interesting experiment assigned adults to complete or partially disrupted sleep, in which researchers monitored inflammatory CRP markers. In all cases, inflammatory markers were elevated in those assigned to disrupted sleep over 10 days of study.5 In addition, inflammation itself has been shown to be causative in disrupting sleep by increasing pain and experiences of worry, anxiety, and depression.5 Chronic inflammation is indicative of a dysregulated immune system, which in and of itself can be another manifestation of hyperarousal.1
Interestingly, those with hyperarousal and increased wake times are less sleepy during the day than regular sleepers, and are more fatigued, but also don’t elevate to a vibrant waking state, nor do they draw towards a natural state of rest when fatigued, which indicates the plague that characterizes the depression associated with insomnia.6
Therapeutic Foods
An anti-inflammatory diet can work as a gene silencing technology, restoring hormonal and genetic balance and stopping the triggers that ignite potential inflammation that could lend towards symptoms of insomnia.7
The use of an anti-inflammatory diet lacks scientific evidence when it comes to insomnia due to complexity of the nature of the studies performed.8 More studies need to be implemented to determine specifics on the effectiveness of anti-inflammatory diets and insomnia, but while 40% of insomniacs are also diagnosed with depression1, it can be useful to look at the research between depression and anti-inflammatory diets. In eleven studies with a participation of 101,950 baseline adults, a significant association was identified between a pro-inflammatory diet and depression.9
The diet consists of reducing omega 6 fatty acids to keep a healthy ratio of omega 6 to omega 3s to 2:1, and consuming fatty fish twice per week. It posits an increase in fruit and vegetable intake, whole grain carbs, and protein largely from plant sources, keeping animal sources to moderate amounts.1
In particular, the relationship between fatty acids and sleep wellness have been well studied. In fact, a study of fatty acids on insomnia with normal weight adults showed a correlation between higher saturated fat intake during the day and shortened sleep cycles with greater nighttime arousals.8
One therapeutic food is salmon. A study of 95 adults consuming salmon three times a week over the course of 6 months was associated with a greater increase in sleep duration and general sleep wellness overall.8
Tryptophan is the pre-cursor to serotonin, an important sleep and wakefulness hormone. Foods that contain tryptophan, like turkey, eggs, and pumpkin seeds could be important to manage circadian rhythm. In a recent study in Japan, it was determined that tryptophan foods in the morning were considered necessary for diurnal rhythm and healthy sleep overall.8
Side effects with common conventional pharmaceutical treatments like zolpidem, trazodone, and amitriptyline can include a mild hangover feeling, cognitive impairment and sleepiness into the waking hours.1 The natural antioxidant effects from elevated plant foods in an anti-inflammatory diet serve well to counterbalance additional toxicities from drug therapies.
One particular difficulty of employing an anti-inflammatory diet is the greater fatigue and reduced ambition in those achieving only poor sleep. One way to counterbalance this potential difficulty could be weekly meal prep, preparing foods for the week ahead of time.
Supplements
Melatonin – Melatonin is a hormone produced by the body, is inhibited in the day, and begins production when instigated by dusk. It has the ability of regulating circadian rhythm, reducing inflammation, and modulating the immune response system.1,10 For the purpose of sleep, the recommended dose is 0.3 to 0.5mg for adults.1,4 A study of melatonin use in adults nightly for 3 weeks was correlated with shorter sleep latency than the placebo group.11
Melatonin has a relatively safe usage profile, however it should not be used in pregnancy. 1 Those with autoimmune diseases will want to pay heed to the questions that have been raised on potential exacerbating effects.1
Valerian – Valerian is an herb with sedative and mildly hypnotic properties, minus the motor impairments known to be common in pharmaceutical counterparts,1,4 making it a common alternative to conventional treatment. Valerian is non addictive and appears effective for mild to moderate insomnia.12 It is often combined with hops, which has anti-spasmodic properties and promotes relaxation. This combination, used in a study of 187mg nightly for 14 and 28 nights showed greater sleep efficiency after 14 nights, with participants reporting significant improvements after 28 days of use.13
Caution should be used in pregnancy or in those with a history of liver disease, and users should be aware of potential herb/drug interactions.1
People to Add To Your Team
CBT-I (Cognitive Behavioral Therapy for Insomnia) combines restructuring of limiting beliefs surrounding sleep with relaxation techniques and sleepy hygiene to address maladaptive sleep associations and improve insomnia. Studies have shown CBT-I to be at least as effective as prescription medication for insomnia without the adverse side effects.1 6 week treatments maintained its positive benefits after a 6 month follow up where participants reported an improved sleep efficiency from 81.4 to 90.1%.14
Conclusion
Effective treatment for insomnia has more to consider than simply learning to relax, and may be a sign of the times in which we are more connected, more exposed to unnatural lights and more hyper-aroused at night than ever. While in some cases a reduction of screen time light is the ticket, in all cases a thorough and comprehensive assessment of the whole person affected is imperative to shine light on the complex puzzle insomnia inevitably presents.
References
Rakel D. Integrative Medicine. In: Integrative Medicine. 4th ed. Elsevier; 2018:320-333.
Perlis ML, Smith MT, Pigeon W. Etiology and Pathophysiology of Insomnia PHYSIOLOGIC MODEL OF INSOMNIA.
Zisapel N. New perspectives on the role of melatonin in human sleep, circadian rhythms and their regulation. Br J Pharmacol. 2018;175(16):3190-3199. doi:10.1111/BPH.14116
Ross K. Insomnia. :1-22.
Meier-Ewert HK, Ridker PM, Rifai N, et al. Effect of sleep loss on C-reactive protein, an inflammatory marker of cardiovascular risk. J Am Coll Cardiol. 2004;43(4):678-683. doi:10.1016/J.JACC.2003.07.050
Circadian Rhythm and Blues: The Interface of Depression with Sleep and Dreams Part II | Psychology Today Canada. Accessed February 12, 2022. https://www.psychologytoday.com/ca/blog/mindful-sleep-mindful-dreams/201105/circadian-rhythm-and-blues-the-interface-depression-sleep
Sears B. Anti-inflammatory Diets. J Am Coll Nutr. 2015;34 Suppl 1:14-21. doi:10.1080/07315724.2015.1080105
Zhao M, Tuo H, Wang S, Zhao L. The Effects of Dietary Nutrition on Sleep and Sleep Disorders. Mediators Inflamm. 2020;2020. doi:10.1155/2020/3142874
Tolkien K, Bradburn S, Murgatroyd C. An anti-inflammatory diet as a potential intervention for depressive disorders: A systematic review and meta-analysis. Clin Nutr. 2019;38(5):2045-2052. doi:10.1016/J.CLNU.2018.11.007
Ross K. Neurotransmitters. :1-7.
Wade AG, Ford I, Crawford G, et al. Nightly treatment of primary insomnia with prolonged release melatonin for 6 months: a randomized placebo controlled trial on age and endogenous melatonin as predictors of efficacy and safety. BMC Med. 2010;8. doi:10.1186/1741-7015-8-51
Block KI, Gyllenhaal C, Mead MN. Safety and efficacy of herbal sedatives in cancer care. Integr Cancer Ther. 2004;3(2):128-148. doi:10.1177/1534735404265003
Morin CM, Koetter U, Bastien C, Ware JC, Wooten V. Valerian-hops combination and diphenhydramine for treating insomnia: a randomized placebo-controlled clinical trial. Sleep. 2005;28(11):1465-1471. doi:10.1093/SLEEP/28.11.1465
Sivertsen B, Omvik S, Pallesen S, et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA. 2006;295(24):2851-2858. doi:10.1001/JAMA.295.24.2851