Jul
22
2016

Anxiety Is Common

By | Anxiety, Mental Health, psychosomatic disease

Recently a review article was published that showed that anxiety is common. This research was conducted in England (Cambridge and London). 48 reviews about anxiety around the globe were examined. The results showed that anxiety in the world population fluctuates between 3.8–25%. Women (frequencies of 5.2–8.7%) and young adults (frequency 2.5–9.1%) are suffering from anxiety more. Among people with chronic diseases there is considerable variation in the frequency of associated anxiety (from 1.4% to 70%).

Variability of frequency of anxiety in different countries

The frequency of anxiety in various ethnic populations varies considerably around the world. For instance European and North American cultures have a relatively high anxiety rate in the population (3.8–10.4%) when compared to Indian and Asian cultures with only 2.8%. In Africa the rate is 4.4%, in Central and Eastern European countries the rate is 3.2%. In North Africa and the Middle East the anxiety rate is 4.9% while in Spanish/Latin cultures the rate is 6.2%.

Anxiety is common and there are subtypes

There are many subtypes of anxiety that have been researched. 

Generalized anxiety disorder (GAD)

This disorder affects 6.8 million adults, or 3.1% of the U.S. population. It seems like women get this condition twice as often as men. The risk for developing it is greatest between childhood and midlife. People with a mild case of GAD can cope and work. Severe cases can be disabling and may be difficult to treat.

Social anxiety disorder

About 15 million US citizens suffer from this. This equally affects women and men. Typically it starts at the age of 13, but 36% of people will not ask for medical help for 10 years or more. Symptoms of anxiety surrounding social situations are so intense that it interferes severely with making friends and having romantic relationships. They end up being alone, powerless against their anxiety.

Panic disorder

6 million US citizens or 2.7% of the population suffer from this. Women commonly are twice as often affected by it than men. Panic attacks develop in early adulthood. They often suffer in silence; distance themselves from friends, family and caregivers who could offer them help. Panic disorders often occur simultaneously with depression and medical conditions like asthma, irritable bowel syndrome and substance abuse.

Specific phobias

19 million or 8.7% of the US population suffer from this. It often starts in childhood and the median onset is at age 7. People affected by specific phobias may be afraid of high bridges, of animals like spiders or mice, of thunder, of flying and a myriad of other things. It disrupts daily routines, causes limitations of work efficiency and reduces self-esteem. It also places a strain on relationships because people afflicted by this problem will do whatever they can to avoid the uncomfortable or terrifying feelings of phobic anxiety.

Obsessive-compulsive disorder

2 million or 1% of the population in the US suffer from this form of anxiety. Onset is in the teenage years, although 1/3 of adults with obsessive-compulsive disorder experienced symptoms already in childhood.

Posttraumatic stress disorder (PTSD)

7 million people or 3.5% of the US population are suffering from PTSD. Women are much more affected by PTSD than men. But a lot of soldiers who were involved in direct combat situations will suffer from PTSD. Rape can be a source of PTSD. Most people who experience traumatic events and develop PTSD will be affected by it for months or even years, but eventually recover from them; a minority will not recover. Often therapy is helpful for these individuals.

Major depressive disorder

8 million American adults or about 6.7% of the U.S population will suffer from depression between the ages of 15 and 44 years. It is more common among women. A certain percentage of depressed people commit suicide. Anxiety is often mixed in with depression.

Persistent depressive disorder

This is a form of depression that persists for at least 2 years. 1.5% of the US population or 3.3 million adults suffer from this condition. The median onset is at age 31. Like with depression, so also with persistent depressive disorder, anxiety is very common.

Anxiety is common; related illnesses

There are many medical diagnoses where anxiety is often part of the symptom complex. The medical profession often talks about psychosomatic diseases. This means that these diseases have an anxiety overlay, which is part of the condition.

  • For instance, bipolar disorder is a condition where extreme mood swings are common, often between elation and mania, but then switching to deep depression with suicidal thoughts. Mixed into this condition is often a certain degree of anxiety, which can be very overwhelming.
  • Irritable bowel syndrome is a psychosomatic disease of the gut with bowel cramps and frequent bowel movements, in others there are periods of constipation. But irritable bowel syndrome often has anxiety attached to it. They are often inseparable.

Eating and sleep disorders

  • Eating disorders: here the person has an intense fear of turning fat. Persons with eating disorder often restrict their calories severely, even when they are underweight. They may exercise for hours with the hope to lose weight. Perhaps the most striking condition among eating disorders is anorexia nervosa, which often affects teenage females, but adult women are affected as well. Sadly many of these women die from starvation or starvation related diseases.
  • Sleep disorders: more than 40 million Americans suffer from chronic, long-term sleeping disorder. Another 20 million suffer from occasional sleep disorder. In addition, often there is stress and anxiety that interferes with the normal sleep cycle.

Chronic pain and fibromyalgia

  • Chronic pain: Pain is a common symptom; if it is associated with a surgical procedure or with an injury it is short lived and eventually goes away. With chronic pain, the pain is present all the time. People with arthritis or nerve injuries that did not heal often have this type of pain. Fibromyalgia sufferers also have this type of pain. When a person has an underlying anxiety disorder and gets chronic pain on top of this, the pain is amplified and becomes even more chronic. On the other hand anybody with chronic pain will suffer from a certain amount of anxiety just because of the chronicity of the pain.
  • Fibromyalgia: this chronic musculoskeletal pain disorder is a special form of chronic pain. About 20% of fibromyalgia sufferers have either chronic depression or chronic anxiety, which certainly complicates the condition.

Substance abuse, stress and headaches

  • Substance abuse: about 20% of people with chronic anxiety disorders have an alcohol or substance abuse disorder; and 20% of people abusing alcohol or having a substance abuse disorder have a chronic anxiety disorder.
  • Stress: too much stress can turn into distress. Distress is an overdose of stress where the stressed person loses control of the situation. This can cause depression and anxiety. It can also cause physical illness.
  • Headaches: migraines, anxiety and depression seem to affect the same population group. Stress and anxiety can cause muscles around the neck to get into spasms and cause tension type headaches. But any headache can be brought on by anxiety.

Anxiety is common; biochemical brain abnormalities

Dr. Kharrazian has summarized in his book that Gamma-aminobutyric acid (GABA), which is a by-product of the brain cell metabolism is responsible for calming the brain (Ref.1). Most noteworthy, this mechanism is not working properly in people with anxiety. In many people with anxiety GABA is simply not produced enough to calm the brain or it gets inactivated too fast resulting in a lack of GABA with anxiety. Consequently, the end result is the same: when there is a relative lack of GABA in the brain the person develops symptoms of anxiety.

Disbalances in neurotransmitters

Disbalances in other neurotransmitters can also contribute to anxiety. As a matter of fact, serotonin is a neurotransmitter that is essential to have for a stable mood and to prevent depression. It is produced in the mid brain. Furthermore, the pineal gland stores serotonin and makes melatonin out of it, which is essential for a normal sleep pattern. When serotonin is low, a number of things can happen. Anger and increased aggressiveness are associated with a lack of serotonin. But depression, obsessive-compulsive disorder, migraines, fibromyalgia, irritable bowel syndrome, bipolar disorder and anxiety disorder are also frequently observed. Many of these illnesses have been noted above to be associated with anxiety. Ref.1 also describes that stress inhibits the conversion of serotonin into melatonin, which therefore explains sleep problems in persons who are exposed to chronic stress.

Anxiety is common; treatment options

In particular, what are the treatment options for a person with anxiety?

Treatment with anxiolytics

It is tempting to just treat the symptoms in an anxious person. But just prescribing anxiolytics like benzodiazepines (like Xanax) will not cure anxiety, just relieve the symptoms for a while. Eventually the body gets used to benzodiazepine and requires higher doses to suppress the anxiety. This can be the beginning of drug dependency, which is not what the health professional or the patient wants. As mentioned above alcohol and substance abuse is already a problem for 1 in 5 people with anxiety.

Treat sleep deprivation

An alternative is to concentrate on treating sleep deprivation in order to help the person to get a good night’s sleep. Melatonin at a dose of 3 mg at bedtime is a reasonable dose to help a person to fall asleep. If during the night the anxious person wakes up again, another dose of 3 mg of melatonin can be given. In addition, if an anxious person lies in bed and ruminates about various things that have happened during the day, a dose of valerian root (500 mg or even 1000 mg) can be useful.

Brain hormone effects

Dr. Datis Kharrazian describes in Ref.1 that valerian root increases GABA at the GABA receptor site. Research has also shown that valerian root slows down the breakdown of GABA. Although GABA is available in health food stores, GABA does not get absorbed through the blood/brain barrier easily. Only patients with autoimmune problems have a leaky blood/brain barrier and GABA can get through, but this is not a good approach to take for treating GABA deficiency. When you take GABA as a supplement, it wears off after a few days and loses its effect. It is wiser to stay away from GABA.

Cognitive therapy and behavioral therapy

This has been proven to help the person with anxiety. Often psychologists specialize in these treatment methods. Meditation and counseling therapy will also help.

Antidepressant therapy

In anxiety cases where depression is part of the psychological make-up antidepressants may have a place for a period of time. The FDA issued a warning in October 2004 about antidepressant medications, including SSRIs. These may lead to suicide and suicidal behavior in a small number of children and adolescents. But there is no way of predicting who will be affected this way. The antidepressant medications are still available and many physicians still prescribe them.

A balanced diet

A balanced diet like a Mediterranean diet provides the nutrients necessary to make GABA. People should avoid sugar in any form as it contributes to anxiety from blood sugar fluctuations.

Yoga and biofeedback

Yoga with an emphasis on breathing techniques can also be useful. Biofeedback methods are useful as well.

Anxiety Is Common

Anxiety Is Common

Conclusion

Anxiety is common, but also very complex, as explained above. 74.8 million Americans suffer from the various forms of anxiety mentioned. Psychosomatic disease often involves anxiety as well and it can be difficult to sort out the symptoms of patients afflicted with physical illness and anxiety. Repeat visits to the treating doctor will eventually help sort these problems out. The physician will rule out any physical problems first by doing lab tests and imaging studies.

Treating anxiety should focus on reestablishing a healthy sleeping pattern. Self-hypnosis tapes or discs are useful. Melatonin and valerian root have their place. Cognitive-behavioral therapy will help the patient to reestablish clear thoughts and minimize the anxiety symptoms. With this approach the patient will often be able to overcome anxiety. There are no instant solutions, but with time and persistence the patient will be able to take back control of his or her life.

Reference

Ref. 1: Dr. Datis Kharrazian: “Why Isn’t My Brain Working?” © 2013, Elephant Press, Carlsbad, CA 92011

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Feb
19
2014

Every Patient Is Unique

By | Anti-aging medicine, Heart Disease, Hormones, Mental Health, Osteoporosis, Vitamins and supplements, Women’s Diseases

Modern Western Medicine tends to see the disease of a patient as a unique entity. Conventional medicine behaves as if a disease is associated with characteristic symptoms, findings and lab test results, which are then treated in a standard fashion by treating the symptoms of the disease.

The reality though is different: The same disease can present in various patients with different symptoms.

Naturopathic physicians, integrative physicians and anti-aging physicians see patients as unique individuals with characteristic personality traits and slightly varied presentations, which may be shared in a disease entity, but differ substantially from person to person.

It is important to be aware of this uniqueness, if the caregiver wants to achieve the optimal treatment result.

Big Pharma does not like this approach as they would like you to think that the conventional medicine system is superior. A certain disease is treated a certain way, preferably with the most expensive drugs.

I thought that in this blog it would be good to shed some light on this important topic.

Menopausal women with symptoms

Let us consider an example of a 55-year old woman who has hot flashes, dry skin, a loss of hair from the outer aspect of her eyebrows, does not sleep well and has lost her sex drive. She also has put on 20 pounds in the last year despite no change in her diet.

This is how conventional medicine would handle this patient

The doctor examines the woman and does a Pap test as well. A conventional doctor would likely order standard blood tests consisting of a complete blood count, thyroid tests (T4, TSH) and FSH and LH levels. The conventional physician would find that the thyroid hormones are low with a high TSH (thyroid stimulating hormone) and would treat the woman with Synthroid (a synthetic thyroid hormone drug). The LH and FSH were found to be high indicating to the conventional physician that the woman is in menopause. He would offer the standard PREMPRO (a synthetic hormone preparation containing a mare estrogen combination with a progestin) with the warning that he will give her the lowest estrogen combination and only up to 5 years because of the negative findings of the Women’s Health Initiative.

Every Patient Is Unique

Every Patient Is Unique

Here is an example how a naturopathic or anti-aging physician’s would investigate and treat the patient

A naturopathic physician or an anti-aging physician would likely add a female saliva hormone panel to the other blood tests mentioned above and also do a T3 hormone level as part of the thyroid blood tests. The doctor will explain to the patient that she was found to be menopausal and also hypothyroid. With respect to the hypothyroidism the physician will explain that apart from thyroxin (T4) there is a second hormone, triiodothyronine (T3) that is also necessary in order to replace all of the thyroid hormones that humans have. Drug companies assume that T4 (Synthroid) will reverse automatically into whatever amount of T3 the body needs, so they have convinced most conventional doctors to prescribe T4 drugs only (like Synthroid). The problem is that as the body ages, the enzymes necessary to convert T4 into T3 do not work as well as in a younger age.This can be verified by testing T3 and T4 levels simultaneously.

The end result is that the patient who only gets T4 replaced may still have some of the symptoms like lack of energy and depression even when T4 has been replaced. Not so with the patient treated by the naturopath or the anti-aging physician who put our patient on Armour (porcine-derived thyroid hormone replacement containing both T4 and T3).

With regard to the blood tests and the saliva hormone tests the second patient was told that the blood tests confirmed menopause (high LH and FSH) and that the saliva female hormone panel showed what was going on. In this particular patient the female saliva hormone tests showed that the progesterone level was low, the testosterone level was low and estrogen was normal. Another hormone, DHEA-S (which is DHEA sulfate, the storage form of DHEA) was also on the low side. Cortisol that had also been tested was normal. The physician explained that the woman’s adrenal glands showed a slight weakness not producing enough DHEA, which is a precursor to testosterone. The low testosterone level was responsible for her lack of sex drive. Progesterone, which needs to be high enough to counterbalance estrogen, was missing, which was likely the cause of her hot flashes and the lack of energy together with the missing thyroid hormones. The physician explained that the woman needed a small amount of DHEA tablets by mouth, a full replacement of progesterone (through the use of a bioidentical hormone cream) and also a small amount of bioidentical testosterone cream to normalize her hormones.

A reassessment of the patients 2 months later showed that the first woman still had some depression and lack of energy, while the second woman felt her normal self again. Both women had regrown their eyebrows from replacing the missing thyroid hormones and have lost several pounds since the beginning of their treatments, but obviously there were quite different clinical results. The first woman was treated in a “standard conventional medicine” fashion, which will lead to breast cancer as unnecessary estrogen was given. She also will be at risk of getting cardiovascular disease as she was replaced with Progestin, a synthetic drug thought by conventional physicians to represent “progesterone”. The Women’s Health Initiative has proven that this was the outcome with PREMPRO and yet this drug is still on the market!

The second woman received an individualized and personalized holistic treatment protocol. The low progesterone from missing her ovulations after menopause was being replaced and her body very quickly responded favorably by making her feel normal again. The missing adrenal gland hormones and testosterone were replaced and this normalized her sex drive. Both, progesterone and thyroid hormones (T3 and T4) are anabolic hormones and they gave her back her energy and restored her sleep pattern. With normal hormone levels she also lost her depression symptoms.

Two men with depression

If you thought that the difference of these two clinical approaches were just coincidental, think again. The next examples are two men in their early 50’s who see their physicians because they felt depressed and had a lack of energy. Both were normal weight.

Here is the conventional medicine approach

The physician took a history, during which a lack of sex drive was also noted. He examined the patient and came to the conclusion that physically nothing was wrong with the man, but a diagnosis of depression was made. This would account for the tearfulness, sleep problems and loss of sex drive. The doctor prescribed one of the standard antidepressants (in this case sertraline, brand name Zoloft). Three weeks later the patient returned and as he was better, a repeat prescription for the antidepressant was given. After a further two months the patient was reassessed. When the symptoms were reviewed, it became apparent that a lack of sex drive was still present, if anything the patient felt the antidepressant had made this worse. Some of the depressive symptoms have improved on the conventional antidepressant. The doctor discussed that the antidepressant could be increased by one tablet per day. The doctor also discussed the option of using Viagra for the decreased sex drive and difficulty having an orgasm.

This would be the  naturopathic or anti-aging physician’s approach. Again similar to before a history was taken and a physical examination was done. The physician noted that the patient was in the age where a lack of sex drive could indicate an early andropause (the male equivalent of menopause, often difficult to spot with the first presentation). A depression questionnaire indicated that the man was moderately depressed. The patient was sent for blood tests and for saliva hormone tests (a male hormone panel). The physician stated that he would like to arrange for cognitive therapy treatment to sort out the various factors of his depression, but also help his mood by trying to start him on St. John’s wort, an herb that has been proven to be effective for mild to moderate depression. The blood work came back as normal. However, the hormone tests showed that testosterone was in the lower third of the normal range. DHEA-S, cortisol and estrogen were normal. So a few weeks later when the tests had come back the patient was called in.  The doctor explained to him that the low testosterone level would explain why his sex drive had deteriorated along with his symptoms of depression. Bioidentical testosterone cream was added to the antidepressant herbal treatment. The result was that within one month this patient’s sex drive was back to normal. Together with the cognitive therapy treatments and the herbal antidepressant the depression was also resolved. After a further three months of counseling he was able to stop the St. John’s wort. Due to the counseling sessions he felt stronger than ever before and his mood remained stable even when the counseling sessions were terminated. He continued to use the bioidentical testosterone cream regularly.

These are examples of two different approaches in two identical men in their early 50’s. It appears to me that the conventional approach did a disservice to the sick person, only treated symptoms, but did nothing to solve this patient’s real problems. The second case’s depression was treated properly and the physician luckily also did not miss the underlying early andropause with low testosterone levels. Repeat testosterone levels showed a high normal testosterone level, which was now in the upper 1/3 of the normal range.

The conventional approach missed the early testosterone deficiency, which  would cause heart disease, should the testosterone levels become even lower. Viagra certainly would not be the answer as this has a number of potentially serious side effects. The antidepressants at even higher doses would cause more erectile dysfunction, which was what he hoped to have treated.

Conclusion

People often have several conditions at the same time. It takes intuition, readiness to do testing, repeat close observation and repeat examination on the part of the physician. This needs to be coupled with good listening skills to sort out a patient. On behalf of the patient it is important to tell the physician all of your symptoms and observations. Be patient and never give up. A good patient/physician relationship will go a long way in sorting out complex medical problems. Every patient is unique. Not every symptom means the same thing in two different patients.

More information on:

1. Menopause: http://nethealthbook.com/hormones/hypogonadism/secondary-hypogonadism/menopause/

2. Depression: http://nethealthbook.com/mental-illness-mental-disorders/mood-disorders/depression/

Last edited Nov. 7, 2014

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Oct
12
2013

Music More Powerful Than Anti-Anxiety Drugs

By | Autism, Cancer, heart attack, Mental Health, Pain, Stress management, Substance abuse

When was the last time you saw your physicians for anxiety and you were given a prescription that said: “for anxiety listen to your favorite music!” instead of receiving a prescription for an anti-anxiety drug (anxiolytic). This is exactly what a recent study suggests that showed prior to surgery you can control your anxiety either with anti-anxiety drugs or by listening to your favorite music. Listening to your favorite music will do you no harm, while many drugs do have harmful side effects.

How singing can change the brain chemistry

Other studies have investigated how singing can change your brain functioning in terms of brain chemistry. The researchers found that singing will release dopamine in your brain, which is responsible for feeling pleasure; it will stimulate your immune system by elevating immunoglobulin A and decreasing cortisol (the stress hormone). This in turn will preserve your immune cells (lymphocytes). Oxytocin levels of your brain are increased, which promotes social affiliation. It also calms down the autonomic nervous system resulting in a better airway opening, calming of your heart rate and soothing the wave-like muscle contractions in your gut, medically called peristalsis. You would refer to that as “butterflies in your stomach”. Music therapy reduces pain and anxiety by 50% and is important for children and adults alike.

Pain and anxiety reduced

A study in Germany showed that pain and anxiety were significantly reduced with music therapy. A Taiwanese study of women in labor found that music therapy significantly reduced pain and anxiety of women during labor. Ref. 1 explains that music therapy is useful as an adjunct to treating cancer pain, and reducing anxiety associated with colposcopy procedures. It also can help when treating patients who had heart attacks in the setting of a cardiac care unit.

Music More Powerful Than Anti-Anxiety Drugs

Music More Powerful Than Anti-Anxiety Drugs

Hypnosis and guided imagery

Music has been successfully combined with clinical hypnosis and guided imagery where words are carefully chosen to help the patient experience pleasant feelings, which counteract the experience of pain, anxiety or fear of dying. A simple relaxation CD or tape with soothing background music will facilitate this type of therapy. This is useful for patients in a palliative care unit where they prepare themselves to accepting the inevitable death from an incurable disease. But chemotherapy patients undergoing these procedures for cancer treatments also have benefitted from a significant reduction in nausea, vomiting (side effects of chemotherapy) and pain.

Autism and music therapy

A Cochrane study showed that autistic children did better in terms of communication skills when music therapy was incorporated into the treatment protocol. One of the core deficits in autistic children is in the area of communication and social skills. This is where music therapy was most effective. Behavioral problems (stereotypic behavior) in autistic children did not respond to music therapy. A comprehensive treatment program for autistic children should therefore incorporate music therapy. Here is a blog that describes what difference music therapy can make in the lives of autistic children written by a member of the American Music Therapy Association.

Substance abuse and music therapy

An area where you may not expect music therapy to have a role is in the area of drug and substance abuse rehabilitation , which is discussed in more detail in this site. The beauty about music therapy is that it is not a drug, yet the natural endorphins that are released by the brain help the affected person getting through withdrawal easier. Music therapy helps building up self-esteem, participating in group activities, promoting self awareness and expressing feelings.

Mood disorders in adolescents

One important area where music therapy has been employed is with anxiety and depression in adolescents. Adolescents spend an average of 4 hours per day listening to music. So they are already programmed to listen to music. With the help of a music therapist they can be directed to listening to the type of music that will help them get motivated, relax more, make them feel accepted and be part of their peer groups. In this study the authors suggested to combine music therapy with dance and art therapy. In this way the whole person gets involved in the treatment and this can be integrated with conventional antidepressant treatments at reduced doses (with less side-effects) or with cognitive therapy.

General objectives of music therapy

Music therapy is best incorporated into a treatment protocol as an adjunct. It can help reduce the use of drugs for psychiatric patients, for people with anxiety and for patients with pain conditions. The Cleveland clinic has a useful summary about music therapy, which describes the uses of it for reducing anxiety, for helping with coping skills, mood improvement and distraction from pain. There are registered music therapists you can ask for help. The website of the American Music Therapy Association may have other useful links for you.

Conclusion

Music therapy is a treatment modality with no side effects, but providing effective treatment for quite an impressive range of clinical conditions as discussed. Music therapists are widely available in the US and many other countries. This treatment can be integrated with conventional or complementary treatments. It helps people to heal the body as a whole unit (mind and body).

More information on anxiety disorders: http://nethealthbook.com/mental-illness-mental-disorders/anxiety-disorders-panic-disorders-phobias-ocd-ptsd-anxiety-others/

References

1. Rakel: Integrative Medicine, 3rd ed.© 2012 Saunders. Chapter on Integrative Therapy; subchapter of Mind-Body Therapy.

Last edited Nov. 7, 2014

Sep
28
2013

Sleepless Nights

By | Health, Hormones, Insomnia, Mental Health, Pain, Prevention, Sleep apnea, Substance abuse, Vitamins and supplements

Sleeping problems (insomnia) are very common. About 10% of the population suffers from chronic insomnia; 30% of the population suffers from occasional sleep problems. In a large outpatient population of a clinic consisting of 3500 patients who had at least one major clinical condition, 50% complained of insomnia, 16% had severe symptoms, 34% had mild symptoms (Ref.1). Insomnia is more common among women, and older people as well as in people with medical or psychiatric illnesses. Long-term studies have shown that the same insomnia problems persist throughout many years. It is not possible to offer a simple remedy for insomnia, because insomnia is a complex problem. Here I will discuss some of the causes of insomnia and also discuss some of the treatment options.

Symptoms of insomnia

The person who suffers from insomnia will usually state that they have problems falling asleep. Worries of the day suddenly circulate through their thoughts and they toss and turn nervously looking at the clock from time to time and getting more and more anxious that they cannot sleep. Others fall asleep OK, but in the middle of the night they wake up perhaps to visit the restroom, but then they cannot go back to sleep. Others wake up 2 hours before their normal alarm clock time and they feel their stomach rumbling making it impossible to fall back to sleep. Older people with chronic diseases and general poor health suffer more from insomnia. In this setting insomnia may be more related to the underlying disease rather than old age. Psychiatric disorders also are associated with more insomnia. Treat the underlying psychiatric illness, and the insomnia disappears.

Although insomnia is a sleep disturbance during the nighttime, people who are affected with this complain of daytime fatigue, of overstimulation, yet they catch themselves making frequent mistakes, and their inability to pay attention gets them involved in accidents and falls. Longitudinal studies have shown (Ref. 1) that people with chronic insomnia are more likely to develop psychiatric disease, such as major depression,  anxiety disorder and alcohol and substance abuse. Unfortunately these disorders can by themselves again cause insomnia, which reinforces chronic insomnia. Insomnia leads to poorer social and physical functioning, affects emotions, leads to a lack of vitality and physical endurance, contributes to worsening of pain and can affect general and mental health.

Research about insomnia

Much has been learnt from sleep studies using polysomnography monitoring during a full night’s sleep. These studies have been used mainly as a research tool. In such studies eye movements, brain wave activity, muscle activity, chest movements, airflow, heart beats, oxygen saturation and snoring (with a microphone) are all simultaneously recorded. This way restless leg syndrome, sleep apnea, snoring, seizure disorders, deep depression etc. that can all lead to insomnia can be diagnosed and separated from insomnia. The stages of sleep (wakefulness, stage 1 to 3 sleep and the REM sleep stage) can also be readily measured using polysomnography (Ref.2). According to this reference the majority of insomnia cases do not need this complex procedure done.

Sleepless Nights

Sleepless Nights

Causes of insomnia

Traditionally insomnia cases are classified into primary insomnia and secondary insomnia. Secondary insomnia is caused by all of the factors discussed below. When they are dealt with, we are left with cases of primary insomnia.

The following medical conditions can cause insomnia: heart disease, pulmonary diseases like asthma and chronic obstructive pulmonary disease (COPD); gastrointestinal disease like liver cirrhosis, pancreatitis, irritable bowel syndrome, ulcers, colitis, Crohn’s disease; chronic kidney disease; musculoskeletal disease like arthritis, fractures, osteoporosis; neurodegenerative disease like MS, Parkinson’s disease, Alzheimer’s disease; endocrine disease like diabetes, hyper- or hypothyroidism, adrenal gland fatigue and insufficiency; and chronic pain conditions. Also, psychiatric conditions like major depression, schizophrenia and anxiety disorders can cause insomnia.

This list in not complete, but it gives you an idea of how complex the topic of insomnia is.
The physician who is seeing a patient with insomnia needs to rule out any of these other causes of insomnia to be certain that the only condition that is left to treat in the patient is insomnia itself. The other diagnoses have to be dealt with separately or else treatment of insomnia will fail.

Ref. 1 points to a useful model of how to think about causation of insomnia: there are three points to consider, namely predisposing, precipitating, and perpetuating factors. Let’s briefly discuss some of these.

Predisposing factors

We are all different in our personal make-up. If you are well grounded, chances are you are not susceptible to insomnia. Anxious persons or persons who have been through a lot of negative experiences in life will have personality traits that make them more prone to insomnia. Lifestyle choices such as late nights out, drinking with the buddies in a bar (extreme circadian phase tendencies) will have an impact on whether or not you develop insomnia.

Precipitating factors

A situational crisis like a job change or the death of a loved one can initiate insomnia.  However, there could be a medical illness such as a heart attack, a stroke or the new diagnosis of a psychiatric illness that has become a precipitating factor. Sleep apnea and restless leg syndrome belong into this group as well as would the stimulating effect of coffee and caffeine containing drinks. Jet lag and nighttime shift work can also be precipitating factors.

Perpetuating factors

Daytime napping to make up for lost sleep the night before can undermine sleep initiation the following night, which can lead to a vicious cycle. Similarly, the use of bedtime alcoholic drinks leads to sleep disruption later that night and can become a perpetuating factor, if this habit is maintained. Even the psychological conditioning of being anxious about whether or not you will fall asleep easily or not the next night can become a perpetuating factor.

I will return to this classification and the factor model of causation of insomnia when we address treatment options.

Drugs that can cause insomnia

One major possible cause for insomnia  can be side effects from medications that patients are on (would belong to the ‘perpetuating factors’ among causes). Physicians call this “iatrogenic insomnia”. The antidepressants, called selective serotonin reuptake inhibitors (SSRI’s) like Prozac are particularly troublesome with regard to causing insomnia as a side effect. Other antidepressants like trazodone (Desyrel) are used in small doses to help patients with insomnia to fall asleep. Some asthmatics and people with autoimmune diseases may be on prednisone, a corticosteroid drug. This can cause insomnia, particularly in higher doses; so can decongestants you may use for allergies; beta-blockers used for heart disease and hypertension treatment; theophylline, an asthma medication and diuretics. Central nervous stimulants like caffeine or illicit drugs can also cause insomnia. Hormone disbalance in general and hyperthyroidism specifically as well as Cushing’s disease, where cortisol levels are high will cause insomnia.

Treatment of insomnia

So, how should the physician approach a patient with insomnia? First it has to be established whether there is secondary insomnia present due to one of the predisposing, precipitating or perpetuating factors. In other words, is there secondary insomnia due to other underlying illnesses? If so, these are being addressed first. Lifestyle choices (staying up late every night) would have to be changed; alcohol and drug abuse and overindulging in coffee or caffeine containing drinks needs to be dealt with. Cognitive therapy may be beneficial when mild depression or anxiety is a contributing factor to insomnia.

The remaining insomnia (also medically termed “primary insomnia”) is now being treated.

The following general points are useful to get into the sleeping mode (modified from Ref. 3):

  1. Ensure your bedroom is dark, soundproof, and comfortable with the room temperature being not too warm, and you develop a “sleep hygiene”. This means you get to sleep around the same time each night, have some down time 1 hour or so before going to bed and get up after your average fill of sleep (for most people between 7 to 9 hours). Do not sleep in, but use an alarm clock to help you get into your sleep routine.
  2. Avoid caffeine drinks, alcohol, nicotine and recreational drugs. If you must smoke, don’t smoke later than 7PM.
  3. Get into a regular exercise program, either at home or at a gym.
  4. Avoid a heavy meal late at night. A light snack including some warm milk would be OK.
  5. Do not use your bedroom as an office, reading place or media center. This would condition you to be awake.  Reserve your bedroom use only for intimacy and sleeping.
  6. If you wake up at night and you are wide awake, leave the bedroom and sit in the living room doing something until you feel tired and then return to bed.
  7. A self-hypnosis recording is a useful adjunct to a sleep routine. Listen to it when you go to bed to give you something to focus on (low volume) and you will find it easier to stop thinking.

Drugs and supplements for insomnia

1. In the past benzodiazepines, such as diazepam (Valium), lorazepam (Ativan), fluorazepam (Dalmane), temazepam (Restoril), triazolam (Halcion) and others were and still are used as sleeping pills. However, it was noted that there are significant side effects with this group of drugs. Notably, there is amnesia (memory loss), which can be quite distressing to people such as not remembering that someone phoned while under the influence of the drug, you promised certain things, but you cannot remember the following morning what it was. Another problem is the development of addiction to the drugs with worse insomnia when the drugs are discontinued. Many physicians have stopped prescribing benzodiazepines.

2. There are non-benzodiazepines drugs that are used as sleeping pills (hypnotics), such as Zaleplon (Sonata), Zolpidem (Ambien) and Eszopiclone (Lunesta).  They seem to be better tolerated.

3. Ramelteon, a melatonin agonist, is available by prescription in the US. It probably is the best-tolerated mild sleeping pill and works similar to melatonin, but is more expensive. Chances are that your physician likely would prescribe one of the non-benzodiazepines drugs or Ramelteon for you as they do not seem to be addicting.

4. However, there is an alternative: Many patients with insomnia tolerate a low dose of trazodone (Desyrel), which is an antidepressant with sleep restoring properties. A low dose of 25 to 50 mg at bedtime is usually enough for insomnia. This allows the patient to fall asleep within about 30 minutes of taking it, and sleep lasts through most of the night without a hangover in the morning. Many specialists who run sleep laboratories recommend trazodone when primary insomnia is diagnosed. However, this is still a drug with potential side effects as mentioned in the trazodone link, but 50 mg is only ¼ of the full dose, so the side effects will also be less or negligible.

5. I prefer the use of melatonin, which is the natural brain hormone designed to put us to sleep. Between 1 mg and 6 mg are sufficient for most people. We know from other literature that up to 20 mg of melatonin has been used in humans as an immune stimulant in patients with metastatic melanoma with no untoward side effects other than nightmares and some tiredness in the morning. A review from the Vanderbilt University, Holland found melatonin to be very safe as a sleeping aid. There are several melatonin receptors in the body of vertebrates (including humans), which are stimulated by melatonin.

6. Other natural methods are the use of L-Tryptophan at a dose of 500 mg at bedtime, which can be combined with melatonin. It is the amino acid contained in turkey meat, which makes you tired after a Thanksgiving meal. GABA is another supplement, which is the relaxing hormone of your brain, but with this supplement tolerance develops after about 4 to 5 days, so it is only suitable for very short term use. Herbal sleep aids are hops, valerian extract and passionflower extract. They are available in health food stores.

Conclusion

A lack of sleep (insomnia) is almost a given in our fast paced lives.

When it comes to treatment, all of the other causes of secondary insomnia need to be treated or else treatment attempts would fail. What is left is primary insomnia. This is treated as follows:

We need to review our sleeping habits, lifestyles and substance abuse. Remove what is detrimental to your sleep. Start with the least invasive treatment modalities such as self-hypnosis tapes, melatonin, L-Tryptophan or herbal extracts. Should this not quite do the trick, asks your doctor for advice. The non-benzodiazepines drugs or Ramelteon would be the next level up. It may be that an alternative such as low dose trazodone would be of help. Only, if all this fails would I recommend to go to the more potent sleeping pills (keep in mind the potential for addiction to them).

References

1. David N. Neubauer, MD (John Hopkins University, Baltimore, MD): Insomnia. Primary Care: Clinics in Office Practice – Volume 32, Issue 2 (June 2005)  © 2005, W. B. Saunders Company

2: Behrouz Jafari, MD and Vahid Mohsenin, MD (Yale Center for Sleep Medicine, Yale University School of Medicine, New Haven, CT, USA): Polysomnography. Clinics in Chest Medicine – Volume 31, Issue 2 (June 2010), © 2010 W. B. Saunders Company

3. Jean Gray, editor: “Therapeutic choices”, 5th edition, Chapter 8 by Jonathan A.E. Fleming, MB, FRCPC: Insomnia, © 2008, Canadian Pharmacists Association.

Last edited Sept. 28, 2014

Aug
01
2005

Cognitive Therapy Useful For Suicide Prevention

By | Mental Health

A prospective study was done involving 120 adults over 18 months with evaluations at 1, 3, 6, 12, and 18 months involving patients who had attempted to commit suicide before entering the study. The purpose of the study was to find out whether cognitive therapy could make a difference in the suicide or suicide attempt rate in the months following an attempt. Several parameters were measured using scales of hopelessness, symptom of depression, frequency of suicidal thoughts and recording repeat suicidal attempts.

The results showed that there was a significant difference between the regular treatment group and the group where cognitive therapy was given. The subsequent suicide attempt rate in the regular treatment group was 1.97-fold higher than in the cognitive therapy group over the 18 months treatment and observation period. 76% of the cognitive therapy treated group did not attempt to commit suicide again (free of repeat suicide attempt), whereas in the regular treatment group this figure was down to 58%. At 6, 12 and 18 moths a depression assessment showed that the cognitive therapy group had a significantly lower (meaning “better”) score than the regular treatment group. This was also reflected in the statistics showing a 50% less likely rate of repeat suicide attempts in the cognitive therapy group. Feelings of hopelessness were also significantly lower in the cognitive therapy group, but interestingly enough there was no significant difference between suicidal thoughts in the cognitive therapy group versus the regular treatment group.

Cognitive Therapy Useful For Suicide Prevention

Cognitive Therapy Useful For Suicide Prevention

The authors came to the conclusion that cognitive therapy is an effective treatment modality, which helps preventing further suicide attempts, in patients who recently have attempted to commit a suicide.

More info on suicide and suicide prevention: http://nethealthbook.com/mental-illness-mental-disorders/suicide-suicide-prevention/

Reference: JAMA. 2005;294:563-570

Last edited October 29, 2014