BioConcepts Insomnia & Sleep

Pathophysiology

Insomnia is characterised by difficulty initiating or maintaining sleep that causes psychological distress and impaired occupational functioning. It results from an interaction of biological, physical, psychological and environmental factors. Chronic insomnia is believed to primarily occur in patients with predisposing factors. These factors may cause the occasional night of poor sleep, but in general the patient sleeps well until a stressful event occurs; this can lead to acute insomnia. If poor sleep habits or other perpetuating factors occur, chronic insomnia develops despite the removal of the precipitating factor.¹

 

Signs and symptoms of insomnia: 

• Difficulty falling asleep
• Sleeping too lightly
• Being easily disrupted
• Multiple spontaneous wakings
• Early morning wakings with an inability to return to sleep 

The exact mechanism behind short term insomnia remains unknown, even though there are many proposed models. There is an emerging consensus that short term insomnia is a disorder of hyperarousal, a state of increased somatic, cortical, and cognitive activation. Measured in physiologic terms, patients with short term insomnia would demonstrate increased cortisol levels, body temperature, 24-hour metabolic rate, and heart rate.²

Initial short term insomnia is often referred to as an adjustment sleep disorder as it’s usually caused by acute situational stress (new job, upcoming deadline, public speaking), eating a heavy meal late at night, hypoglycaemia, exposure to an allergen, time zone change, short term pressure with an end date and emotional upset. These disturbances are not related to any other medical disorder, substance use, or prescription use.³

A recent update of the DSM also classifies short term insomnia as potentially lasting for 1-6 months and is usually associated with persistent stressful situations, environmental factors such as noise, excessive light exposure and consistent electromagnetic exposure (blue light, phone, computer, television, electric blanket, wifi).³

Chronic insomnia lasts more than 6 months and is associated with a wide variety of disorders. Each presentation calls for a tailored approach to address the upstream cause:¹

• Neurological: headache syndromes, chronic pain, depression, anxiety disorders (PTSD, panic disorder), nocturnal enuresis, Schizophrenia (mania phase) and bipolar Parkinson’s disease, Alzheimer's disease, epilepsy, multiple sclerosis and traumatic brain injury
• Endocrine: diabetes, thyroid dysfunction, hormonal changes (menopause, pregnancy) 
• Latrogenic: Medications, medical procedures
• Metabolic: obesity, hypertension, hypercholesterolaemia, sleep apnoea/ COPD, renal disease
• Gastrointestinal: parasites, reflux
• Musculoskeletal: spinal instability, restless legs
• Other: shift work

Medications commonly prescribed for insomnia include: 

• Antidepressants (SSRI, TCA)
• Barbiturates
• Benzodiazepines
• Hypnotics/ sedatives
• Sedating antipsychotics
• Sedating antihistamines
• Melatonin

Primary Assessments:

Insomnia is closely linked with many different conditions as discussed above; testing will vary according to the presentation and various drivers. The primary tests include:

• 24 hour urinary or salivary cortisol
• Iron Studies – iron, TIBC, saturation, ferritin
• Thyroid Function Tests – TSH, active T3 & T4, reverse T3, T3 to reverse T3 ratio, TPOAb, TGAb

• 10 minutes of early morning sunlight on face and through closed eyelids to support circadian rhythm and melatonin production
• Choose organic where possible – from your mattress to your sheets ü  Keep the bedroom ventilated: open windows or consider a HEPA filter
• Remove problematic furniture / furnishings contributing to chemical toxic burden or expose new furnishings to sunlight and air (accelerating the process of ‘off gassing’ - heat removes toxins)
• Create healthy boundaries with electronic devices and keeping them on aeroplane mode when not in active use (including sleep tracking devices) ü  Avoid screen use at least a few hours before sleep; change settings on screens to avoid blue light emissions or consider blue light blocking glasses
• Turn bedroom electronics off at the power point when not in use and avoid positioning bedheads close to household power boxes on external walls
• Adequate protein with dinner will maintain steady blood glucose levels, making wakings due to hypoglycaemia less likely
• Eat dinner 2-3 hours before bedtime to allow ample time for digestion, especially in those with reflux disorders
• Avoid or minimise caffeine after 10am, or avoid caffeine altogether temporarily until insomnia has improved