Insomnia and Its Implications

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

Sections
The United States National Institute of Neurological Disorders and Stroke, a department of the National Institutes of Health (NIH), states that: "At least 40 million Americans suffer from chronic, long-term sleep disorders each year, and an additional 20 million experience occasional sleeping problems...For short-term insomnia, doctors may prescribe sleeping pills. Most sleeping pills stop working after several weeks of nightly use, however, and long-term use can actually interfere with good sleep." By 2016, these statistics were revised upward, with the U.S. NIH National Heart, Lung and Blood Institute creating The National Center on Sleep Disorders Research (NCSDR), which stated that "about 70 million Americans suffer from sleep problems; among them nearly 60 percent have a chronic disorder." The costs of this health problem are conservatively estimated at adding about $16 billion yearly to national healthcare costs, and much more than this in lost productivity, costs of accidents, and mistakes by workers in many industries. The NCSDR stated that sleep disorders require multidisciplinary approaches to treatment.

The need to integrate Complementary Medicine (CIM/TCM) and Sleep Hygiene to treat chronic insomnia is apparent. For decades, the pharmaceutical industry has introduced one after another sleep medications that have been proven to be only mildly effective and have come with alarming adverse effects with chronic use, as well as a rebound effect addiction, yet each time a new sleeping pill is approved, it is touted as the miracle cure for insomnia and completely safe. None of these sleep medications actually corrects the underlying multifactorial health problems that cause insomnia. Chronic insomnia is a symptom that is secondary to another health problem, problems or disease, and not a primary disease. Integrative Complementary Medicine, in the form of acupuncture, herbal and nutrient medicine, physiotherapies, and patient instruction in sleep hygiene and various relaxation techniques, may not only improve symptoms of chronic insomnia, but also address the numerous underlying health problems that cause, or are caused by, chronic insomnia. A focus on insomnia instead of the health problems causing insomnia has led to widespread anxiety about sleep quantity and a lack of focus on sleep quality. For instance, temporomandibular disorders (TMD), formerly just referred to as the joint of the jaw, or TMJ, and cardiovascular health are now strongly implicated in Sleep Disordered Breathing, formerly relegated to the problem of sleep apnea alone, and treated only with a problematic CPAP machine. Problems related to poor sleep quality such as nocturnal bruxism and Restless Leg Syndrome represent movement disorders that are related to TMD and neurovascular regulation of the heart rate and blood pressure during sleep cycles. Finally, standard medicine is defining insomnia as a health problem that is complex and not solved by the simple-minded strategies of the past.

A 2007 study by the National Sleep Foundation, a nonprofit research group, entitled "Women and Sleep", found that nearly 30 percent of women in the United States used some type of aid to sleep at least a few nights per week to combat chronic insomnia. These sleep aids range from herbal remedies to nutrient supplements to complex pharmaceuticals (typically Ambien or the generic Zolpidem). Melatonin supplements are becoming popular in bars and convenience stores, as many patrons believe that a drink with melatonin or a brownie with the supplement will provide the aid to sleep and relaxation they need without the side effects of a prescription medication, but with little to no regulation of commercial supplements in the United States we find now that many of these off-the-shelf herbal and nutrient medicines do not contain what they say they are made of, and more and more mild adverse effects of non-professional herbal and nutrient products are being reported because of this lack of formal regulation and enforcement of quality. Pharmaceuticals are now prescribed with little thought of benefit versus risk, and a high percentage of the population is now having problems with both insomnia and its implications, and with the treatment of their insomnia. Professional care in CIM/TCM will utilize short courses of acupuncture stimulation and physiotherapy, with individualized herbal and nutrient therapy that addresses an array of health concerns related to poor sleep quality, and will provide professional herbal and nutrient medicines that are of assured quality and content.

In 2016, the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute released a study that showed that a third of adults in the United States slept less than 7 hours per night and experienced poor sleep quality, which was associated with numerous health problems, such as high levels of depression, hypertension, heart and kidney disease, as well as higher incidence of motor vehicle accidents and suicide. Obviously, sleep medications, hypertension drugs, and antidepressants were not solving these problems, just masking the effects of this very prevalent and serious set of disorders. A more holistic approach is needed. While the emphasis has shifted to sleep quality rather than sleep quantity as the important health factor in these studies of health problems related to poor sleep, we still see a strong belief that only the number of hours of uninterrupted sleep per day is important. We are seeing that serious health problems associated with less sleep are most often due to the very factors that are causing this deficiency of sleep, and simply taking pills to increase the time spent sleeping will not prevent these comorbid health problems from occurring.

Most insomnia disorders involve a number of health factors that create a cycle of dysfunction, and cannot be attributed to a single factor that disturbs sleep quality. Research shows that neurohormonal imbalance, poor regulation of vagal responses during the sleep cycle changes, gastroesophageal dysfunctions affecting the cardiac sphincter and vagal response, poor coordination between areas of the brain associated with memory and mood, poor regulation of diurnal cortisol, and excitotoxicity in the brain may all contribute to dysfunction in the sleep cycle, or just some of these problems may be occurring. While none of these health problems may be clinically severe on their own, they may all contribute, making the study of insomnia and appropriate treatment the difficult problem that it still is. In addition, a number of common subclinical diseases, such as sleep apnea, thyroid pathology, and metabolic syndrome, as well as musculoskeletal problems, chronic inflammatory conditions, COPD, diurnal hypertension, kidney disease and neurodegenerative disorders may contribute to the sleep disorder. Each individual should assess their health history and address any of these underlying health problems, some of which could present as a subclinical disease and be overlooked. Holistic medicine provides the potential for a more complete assessment.

Standard medicine has responded this difficult and complex situation by treating all insomnia as a single health problem, and providing sedation with barbiturates, anti-histamines, benzodiazepines, anti-depressants, hypnotics and GABA agonists, all of which create health problems themselves, and which we adapt to, decreasing the effectiveness. Newer sleep drugs include orexin receptor antagonists, which block the sleep regulatory neurohormone hypocretin, have been fast-tracked in FDA approval, and independent reports, such as this one by Consumer Reports, show that benefits may be slight, while long-term risks have not been adequately assessed - click here to see this report: http://www.consumerreports.org/cro/news/2015/07/skip-new-insomnia-drug-belsomra/index.htm. As with many newer medications, the cost of these new sleep drugs, such as Belsomra, are very high, with reports of an average cost for the drugs at $275.00 per month! Complementary and Integrative Medicine (CIM) provides an holistic and individualized approach to address these many underlying health concerns, and while the treatment effect may not be as immediate as taking an Ambien, the improvement in sleep quality and overall health with this more complex therapy provides a valuable result in the end without chemical dependency. Short courses of acupuncture may address some of these factors causing insomnia, and specific herbal and nutrient medicine others, and if necessary, soft tissue physiotherapy, or Tui na, can help alleviate nagging pain and discomfort. In recent years we are seeing more and more sound research supporting these many positive effects in CIM, but patient understanding is of course the key to making this work - hence the need for this lengthy article.

While it is tempting to define a health problem by the symptom remedy and ignore the underlying implications of the health problem or problems that are causing it, this is not the sensible long-term solution to the problem of chronic insomnia, sleep disorder, or anxiety-associated insomnia. Insomnia syndromes are often resulting from an interaction of biological, physical, psychological, and environmental factors that need to be addressed with a holistic approach, and if the physical or biological disorder is related to an endocrine or metabolic imbalance or pathology, this needs to be identified and corrected. Often, a chronic insomnia or sleep disorder is the first tangible sign of a developing and serious health problem. While infrequent episodic insomnia, especially related to unusual events or worries, is perfectly normal for a healthy individual, chronic and frequent insomnia needs to be assessed professionally. Ignoring the underlying health problems causing this symptom may result in more serous problems in the future. The time to correct these health problems is before they develop into a more severe condition, and Complementary and Integrative Medicine (CIM), acupuncture with herbal and nutrient medicine, and even Tui na physiotherapy, when musculoskeletal pain is keeping you awake, provides an array of therapeutic protocols that are now proven to work.

Standard pharmacological treatment for insomnia has been problematic for decades, with the findings of risks and adverse effects often outweighing the benefits. Even standard medicine has turned to sleep clinics promoting an array of sleep hygiene protocols instead of, or to complement, drug therapies. Sleep hygiene, or the regulation of the whole array of behavioral and environmental factors that precede and interfere with sleep, is an integral part of the protocol in Traditional Chinese Medicine, combined with herbal and nutrient medicines, acupuncture stimulation, and physiotherapies, to holistically address both the insomnia and its causes and associated health problems.

As research progresses we are reaching the final stages of human clinical trials of various individual therapies in Complementary and Integrative Medicine and Traditional Chinese Medicine (CIM/TCM), and the results are providing positive findings of potential benefits from a variety of treatments. In the clinical setting, these simple treatments are combined to provide an even greater potential for success with an integrated holistic protocol, and individualized for each patient. The potential to eliminate the underlying causes of chronic insomnia presents the patient with the potential to rid themselves of this problem that decreases quality of life and work potential for good, with no future dependency on treatment, especially drug addiction, and no rebound effect. This is where the complementary and holistic protocol differs from the allopathic approach. Finding the right set of integrated treatment modalities that works for each individual, and then adjusting that treatment protocol as the conditions improve to finally restore quality sleep without therapy is the goal in TCM and Complementary Medicine. Integration of Complementary Medicine may also be needed when dependency and addiction to sleep medications occur.

Understanding Insomnia is Necessary to Design the Right Restorative Treatment Protocol

Defining insomnia as a specific disorder has long been a challenge for allopathic medicine. The NIH states that doctors have described more than 70 sleep disorders, and often proper treatment is effective only after a correct diagnosis. The experience of insomnia is extremely varied, both in type and frequency, and normal sleep patterns for some individuals would be considered a significant problem for others in terms of function and quality of life. Generally, insomnia is reported as either a difficulty falling asleep, a problem with waking during the night, or both. Even the patient with a frequent insomnia may wake perfectly rested, and their is no specific physiological need for a specific number of hours of sleep for all individuals. We see this most dramatically with the parents of an infant, whose sleep is disturbed by the care of the baby, yet functionality and quality of life is maintained. On the other hand, some patients may sleep for relatively long periods of time and still not feel rested. Sleep clinics may study the sleep cycle with polysomnography, to see if the normal sequence of sleep phases occurs, which is important for the healthy function of the central nervous system, although this is usually expensive and only performed when a serious sleep apnea is suspected. Understanding insomnia on an individualized basis and addressing both the symptoms and the underlying causes and contributors is important, and developing a holistic protocol that addresses the biological, physical, psychological, and environmental factors to achieve real success should be the goal, not just taking a pill to sleep.

In 2001, experts at the Stanford University Center for Narcolepsy, Dr. Marcel Hungs and Dr. Emmanuel Minot, stated in a landmark paper on hypocretin and orexin, 2 key chemicals that help regulate wakefulness, that: "The function of sleep and why this behavior was selected by natural evolution is one of the remaining mysteries in physiology today." In other words, despite what we read, we still do not really know if a steady 8 hours of sleep is even necessary for human health.

In recent years, a number of sleep experts have noted that descriptions of sleep in history often mention the 'first sleep' and the 'second sleep', describing a pattern of sleep that involved waking in the middle of the night and resting awake, or working, for an hour or two. This segmented sleep, or biphasic sleep pattern, has now been thoroughly researched, and appears to be a natural sleep pattern for humans, along with a short nap during the day. Many cultures still promote a midday nap, or siesta, cat nap, or power nap. Historians A. Roger Ekirch and Craig Koslovsky have found abundant evidence of the prevalence of this habit, with the midnight waking state used to contemplate, pray, write poetry, write religious text, meditate, or even for couples to have more relaxed and meaningful sex. Sleep studies have confirmed these findings, with subjects denied artificial light adopting a segmented sleep, and higher levels of prolactin secreted during the midnight wakeful state, which is associated with peaceful mood, healthier reproductive capability, and many neurohormonal and immunological benefits. Dopamine and prolactin are now known to cause, or be associated with, sexual arousal and sexual satisfaction. Prolactin is also a promoter of brain cell maintenance and growth. Normally, there is both a diurnal and ovulatory cycle to prolactin secretion, and it is hypothesized that higher levels in the midnight waking state could be beneficial in a number of ways. For many, anxiety about waking in the middle of the night may be unwarranted, and a more relaxed attitude and utilization of this midnight waking state could result in a more relaxed and healthy feeling during the day. It is the quality of the sleep, not the quantity, that is important, and there are a number of ways to improve the quality of sleep. A healthy sleep cycle is found to be an important tool for cognitive function and sorting of memory and data. The sleep cycles are relatively short, and even a 20 minute nap has been shown to be able to achieve this cognitive sorting and improve test scores and mental function.

The science of Traditional Chinese Medicine (TCM) looks at the symptom of insomnia from a holistic perspective that incorporates a traditional health profile combined with a modern medical assessment. In TCM, insomnia is a symptom that often reveals a type of imbalance of homeostasis as the key underlying cause, if it is not directly related to, or secondary to, a specific psychological disorder or disease as the predominant cause. Both the traditional and the modern perspective should assess the insomnia first as a primary disorder or secondary to another health problem. Four types of insomnia are traditionally assessed: 1) difficulty falling asleep, 2) waking inappropriately, 3) restless or light sleep, and 4) inability to sleep much at all. Each type of insomnia has a differential diagnosis related to the basic imbalances of yin and yang, excess and deficiency, and the visceral systems, in the traditional Daoist assessment, as well as a differential set of health problems that may be associated with each type. The Licensed Acupuncturist and herbalist must assess the symptom of insomnia both in terms of a holistic diagnosis and with a modern medical assessment, which often requires a thorough evaluation of each individual's health history.

One of the most important considerations in this assessment is the presence of underlying health problems causing or contributing to the insomnia, and these issues should be addressed to really achieve success with Complementary and Integrative Medicine. The Mayo Clinic lists these conditions as most often causative of, or contributing to, insomnia: chronic pain, breathing difficulties, nocturia, arthritis, lung disease, gastroesophageal reflux, overactive thyroid, stroke, Parkinsons or Alzheimers disease, cancer, or heart failure (congestive heart disease). The TCM physician assesses both the homeostatic health and the related diseases or injuries, and first tries to treat a potential primary cause. Getting to know the patient is the first step in analyzing a differential diagnosis. If none of these obvious potential causes of sleep arousal are evident for the individual, the TCM physician proceeds to treat the type of insomnia as a primary pathology, and to assess various imbalances that may contribute to the disease. A broad array of health issues may be addressed in Complementary and Integrative Medicine. Even if the patient chooses to treat with a sleep medication, utilizing TCM and Complementary Medicine to address these common causative or contributing health problems will not only cut down on the need for expensive medication, but will improve the overall health and potentially eliminate the need for the medication in the long term.

While most patients with a sleep disorder now question the efficacy of simple herbal and nutrient medicines in regulating sleep, while utilizing pharmacological remedies with almost no questioning of efficacy or safety, this is proving to be largely due to a systematic campaign of massive advertising and a strong bias against Complementary Medicine. The goals in therapy for Complementary Medicine are to not only provide better quality sleep, but also to address the underlying causes of chronic insomnia. The perception of poor efficacy of herbal and nutrient medicine may be largely due to a lack of individualized and comprehensive holistic treatment protocol utilized, as well as a lack of quality control in the over-the-counter products, which numerous studies have found to be a prevalent problem. Utilization of such an individualized and holistic protocol, with professional products assured of quality, and proven herbal and nutrient medicines used properly, in the right combination and dosage, and combined with short courses of acupuncture, sleep hygiene advice, and cognitive and behavioral changes, is rare. Most patients simply pick up an advertised natural sleep aid at a store without questioning quality and individualized efficacy, or take what their medical doctor prescribes without question.

Integration of safer Complementary Medicine is also rare in the standard medical community, but this is changing. In recent years, leading experts in the field of sleep disorders have proven in studies that the benefits of the most common sleep medications may be minimal for most patients, while the potential adverse effects from chronic use may be complex, difficult to analyze, but alarming. This is leading to gradual acceptance of CIM/TCM in standard medicine in the realm of achieving healthier sleep and restfulness.

In 2010, a large long-term randomized controlled human clinical trial of cognitive behavioral therapy and zolpidem (Ambien) was published in Evidence Based Mental Health, conducted at the University Hospital Sleep Center, in Quebec, Canada. These experts found that a short course of cognitive and behavioral sleep hygiene therapy was effective, and that while adding Ambien to the protocol improved sleep time by about an average of 12 minutes, randomized controlled polysomnography measurements did not show benefit. The advice from these sleep experts was to discontinue Ambien during maintenance therapy with cognitive and behavorial sleep hygiene therapy (Evid Based Mental Health 2010;13(28) / JAMA 2009;301:2005-15). Dr. David L. Streiner of McMaster University, Department of Psychiatry, Toronto, Canada, concluded that adding zolpidem (Ambien) to a cognitive and behavioral sleep hygiene treatment produces very limited benefits in persistent insomnia. As this research was being released, the pharmaceutical industry was introducing the next sleep medication, Suvorexant (Belsomra), from Merck, an inhibitor of a sleep regulating chemical produced in the hypothalamus called orexin, also called hypocretin. A 2013 article in the New Yorker, entitled The Big Sleep, revealed that the U.S. FDA team investigating approval of this new drug presented unusual questions in review of the study data on Suvorexant. Instead of looking just at standard safety issues, these experts targeted numerous reports in clinical trials of patients reporting disturbing dreams, waking suddenly and temporarily unable to move or speak, and sleep walking, much like is reported with Ambien. Ambien primarily affects the function of GABA receptors in the brain, and primarily affects the ability to fall asleep, not the maintenance of sleep, while this new drug primarily affects the maintenance of sleep by inhibiting a chemical in the brain that promotes waking, orexin. Both drugs produce potential adverse effects on regulation of mood, negative thoughts, and control of awareness during wakeful activities, such as sleep walking. Both drugs are shown to produce rebound insomnia if the drug is taken too often and for too long, when the patient tries to discontinue the drug. At higher dosages, or accumulative effect, both drugs would have similar adverse effects to benzodiazepines and histamines, producing daytime drowsiness and problems with focus and attention. In other words, sleep medication is being refined, and has some proven effectiveness, but is not particularly safe to take too often or for too long, or at too high a dose. Complementary Medicine and cognitive behavioral sleep hygiene needs to be integrated into the treatment protocol for persistent insomnia, and these therapies are inexpensive, healthy, and proven effective if guided by a knowledgeable physician.

Finally, in 2012, even standard medicine is realizing the problems with merely prescribing a one-size-fits-all sleeping pill. For instance, The American Geriatrics Society (AGS) updated the Beers Criteria for potentially inappropriate medication use in older adults, and recommended avoidance of popular medications prescribed for insomnia and agitation, such as benzodiazepines, barbituates and chloral hydrate. Gradually, the advice in standard medicine is to utilize a multidisciplinary approach that is individualized to address sleep quality, and to approach the problem with a more holistic mind-body protocol.

Benzodiazepines are widely prescribed in the population and present a number of health risks, including an addictive quality and rebound syndrome, where trying to stop taking them daily results in alarming symptoms of increased agitation, high blood pressure and panic. In addition, both benzodiazepines and the popularly prescribed hypnotic sedative Ambien (zolpidem tartrate) come with FDA warnings concerning incidence of behavioral changes and abnormal thinking, including instances of complex sleep-walking behaviors. The AGS (American Geriatric Society) stated: "Older adults have increased sensitivity to benzodiazepines and slower metabolism of long-acting agents. In general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults. Avoid benzodiazepines (any type) for treatment of insomnia, agitation, or delirium." The array of brand names for benzodiazepines is large, but most of the pharmaceutical names end with the suffix -pam. The AGS also recommended avoidance of nonbenzodiazepine hypnotics and sedating histamines, stating: "Benzodiazepine-receptor agonists that have adverse events similar to benzodiazepines in older adults (e.g. delirium, falls, fractures); minimal improvement in sleep latency and duration. Avoid chronic use (> 90 days)." An article in the April 17, 2012 New York Times, Science Times, speaks of the common practice of overprescribing medications to the elderly and the harsh implications of drug interactions with chronic use. The health journalist, Jane E. Brody experienced a personal dosage of this practice when her aunt was hospitalized, and nearly died, from the effects of her medications, which were not extraordinary, and included a benzodiazepine (alprazolam, or Xanax), an anti-depressant, blood pressure medications (adrenal receptor block plus angiotensin receptor block), an anti-psychotic variant for Alzheimer's, and a synthetic thyroid hormone. This combination of drugs built up effects in a slower aging metabolic system, causing severe confusion, sleepiness and extreme weakness, including neurological and metabolic effects, in this case a very low sodium level in circulation, as well as precipitous drops in blood pressure, disorientation, and finally a fall with bone fractures. The author noted that the AGC panel now recommends 'alternative' sleep remedies for older adults, such as an herbal and nutrient aid, sleep hygiene, or even acupuncture. These conservative therapeutic options should be considered the initial approach to try, though, and not an "alternative", with problematic sleep drugs only used when such completely healthy options don't work, or used only when needed, not continuously. The persistence in characterizing safe, effective and inexpensive holistic therapies as 'alternatives' to real medicine, rather than integrative therapies, is absurd.

A thorough health history is important in understanding the individual causes and contributors to insomnia, so that a more holistic protocol can be designed. For instance, stomach excesses with acidity or fullness may cause an inability to fall asleep or waking inappropriately, and metabolic imbalances related to the liver and kidney are also suspect. The liver is the workhorse of the body's metabolism, and is most active between 2 to 4 am, as the organ becomes engorged with blood and resets the metabolic balance in its diurnal pattern. Restless sleep may be related to the cardiovascular and adrenal systems, or disharmony between the heart and kidney systems, with autonomic dysfunction. Always, overt causes such as chronic pain flaring at night, problems causing nocturia, bruxism, apnea, or tachycardia are explored. In modern medicine, such causes should also be assessed on an individual basis, and emotional disturbances, digestive function, metabolic imbalances (e.g. leptin regulation), and adrenal dysfunction (e.g. diurnal cortisol levels) are commonly explored. A proper integration of standard medicine and TCM achieves the appropriate testing and thorough assessment needed to make the differential diagnosis, and then proceeds to the most conservative holistic therapeutic protocol. The type of insomnia may help the physician find the health problems causing or contributing to this symptom, and properly assessing the whole health picture and addressing these underlying causative health problems may be the key to success. If an important underlying health problem or problems are not addressed in therapy insomnia may persist despite any type of therapy. In addition, if underlying health problems causing or contributing to insomnia are merely masked with the use of a sleeping pill, these health problems are often not addressed. By addressing the underlying health problems future disease of a serious nature may be prevented, and overall health and quality of life improved now. This holistic approach makes sense on a number of levels.

The Complementary and Integrative Medicine (CIM) physician often takes the time to help solve the puzzle of underlying health problems, and form a treatment strategy that addresses these problems. In standard medicine it is often difficult to obtain the time needed from the attending medical doctor, and too often a prescription for sleep is written without proper assessment. When a number of health factors are contributing to a problem these need to be addressed as a whole, not just treating one piece of the puzzle, and certainly the chemical inducement of sleep does not really address these problems. Integrative Medicine will help address the implications inherent in the problem of chronic insomnia and sleep disorder, as well as provide treatments for immediate relief of insomnia. The choice is not just between the pharmaceutical or the complementary therapies. Even if the patient chooses to utilize a sleeping medication, addressing the underlying health issues is important, and a responsible patient will utilize a Complementary Medicine physician, such as a Licensed Acupuncturist, to address these health issues, as well as to decrease potential advese effects of the medication.

The importance of treating the underlying causes of insomnia rather than just masking the problem with sleeping pills

It is estimated that 75-90 percent of patients seeking medical care for chronic insomnia have a comorbid condition, or a causative or contributing health problem. A large long-term study of thousands of patients by the University of Wisconsin, published in 1998, found that cardiopulmonary disease, painful musculoskeletal conditions, depressive disorders, and prostate problems were frequently associated. Women and older patients made up a high majority of cases, with insomnia worse during the menopausal, or perimenopausal years, and during the menses in women prior to menopause. Hormonal fluctuations obviously are highly correlated with insomnia. A broad study at the Sleep Disorders and Research Center at the Henry Ford Hospital in Detroit, Michigan, in 2007, estimated that over 30 percent of the population suffers from chronic insomnia (more than 4 months and at least 3 times per week), with impairment of cognitive and physical function. Patients suffering from chronic insomnia are shown to have more accidents, higher rates of job absenteeism, diminished job performance, decreased quality of life, and increased health care utilization. Approximately 40 percent of patients experiencing chronic insomnia have diagnosable psychiatric problems, most frequently depression and anxiety, and medications that treat these problems, antidepressants and benzodiazepines, are now well known to cause reduced REM, problems with quality of sleep and sleep cycles, increased waking insomnia, and sometimes even problems falling asleep.

Hypothalamic dysfunction with abnormal regulation of corticotropin-releasing factor (ACTH) and diurnal cortisol responses in the adrenals is central to most cases of both insomnia and depression. Most of the activity of orexin and hypocretin, neurohormonal chemicals that regulate wakefulness, also occurs in the Hypothalamus. Restoration of the homeostasis of a healthy hypothalamic / pituitary adrenal axis is important not just to resolve insomnia, but for the whole health and healthy aging.

Diurnal cortisol levels are the most frequently used laboratory assessments for this condition, and cortisol levels in the evening and night are elevated from normal for a majority of these patients. Both urinary and blood plasma levels of cortisol and adrenocorticotropic hormone (ACTH) have been used to confirm that excessive evening and night secretion of adrenal cortisol related to hypothalamic dysfunction is the most frequent physical abnormality associated with insomnia, as well as depression with anxiety mood disorders (see study summary below). In 2001, the Sleep Research and Treatment Center at Pennsylvania State University College of Medicine conducted a controlled study of patients with chronic insomnia matched to healthy subjects for a four night study, finding that higher levels of cortisol, and ACTH were clearly associated with sleep disturbance, and a significantly higher number of pulsatile peaks of cortisol were associated with the degree of sleep disturbance. Even patients with a normal circadian rhythm of cortisol secretion experienced increased pulsatile peaks of cortisol leading to hyperarousal. These sleep experts stated that such findings suggest that insomniacs were at increased risk for mental disorders, especially chronic anxiety and depressive mood disorders. Such studies have led to a strong emphasis on a holistic approach to chronic insomnia, not just a protocol of taking a sleeping pill. Cognitive approaches, sleep hygiene, and a holistic restoration of the hypothalamus adrenal axis need to be combined to truly treat this health problem.

Testing for hormonal imbalances has become easier and less expensive. Active hormone metabolites in saliva samples may be sent analysis and reveal cortisol and adrenal imbalances, as well as contributing imbalances between estradiol and progesterone. A set of samples will reveal the diurnal levels of cortisol to assess whether the hypothalamic-adrenal regulation of cortisol is improper, or whether adrenal insufficiency or imbalance of steroid hormones is contributing. Often, an adrenal stress syndrome is involved, which can be corrected with a holistic approach and hormonal balancing. Simple tests with veinous blood stick samples may reveal a subclinical thyroid dysfunction, and point to the exact area in the thyroid cycle of regulation that shows dysfunction. Levels of the hormone Vitamin D may be assessed as well. A thorough diagnostic workup is necessary to arrive at an individualized assessment of the health problems creating or contributing to chronic insomnia. A holistic approach is often necessary, as treating just one part of a cycle of dysfunction will not correct the problem. While standard medicine continues to deny patients this holistic workup with analysis of active metabolites of hormones in saliva and veinous blood, the Complementary Medicine physician, such as the Licensed Acupuncturist and herbalist, or the Naturopathic Doctor, may provide these tests and expert analysis at low cost, to guide individualized holistic restoration of health.