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I can’t sleep! Can I take something for this? I’ve never really been able to get good sleep. It takes me forever to fall asleep. Drinking helps.
One of the most prevalent concerns of our patients at CeDAR is poor sleep. Sleep disruption is incredibly common amongst those struggling with alcoholism, drug addiction or other mental health concerns such as major depression or anxiety. Because insomnia gets so tiring (pun intended), many people relapse around alcohol just to get a good night’s sleep. This rejuvenates the addiction cycle, creating more chaos and dependency on substances and greater suffering.
This is the first of a series of articles looking further into sleep, including the brain pathways involved, medication options, and behavioral therapy. Sleep issues can also be symptoms of severe health problems which may need medical attention.
Much of what we know about the brain and sleep is based on what is called sleep studies. A sleep study is where a subject sleeps in a quiet, medical setting and is monitored with an electroencephalogram (EEG). This test tracks electrical conduction in the brain and gives a report showing waves of multiple sorts. A researcher can look at the EEG report and determine certain traits of the sleep. This is also how we can categorize sleep into different stages.
Sleep is divided into Rapid-Eye Movement (REM) sleep and Non Rapid-Eye Movement (NREM) sleep. A person who drifts off into sleep will spend different lengths of time dropping through the stages. A useful metaphor for this process is that of a snorkeler who dives down to the ocean floor. Our brains will make a few ‘dives’ each night, and the length of time in each sleep stage is important for such topics as dreams, memory, restfulness and physiological responses including blood pressure and oxygenation.
Diagram of Sleep Stages and 4 Quality “Dives”
Healthy individuals will spend about 75% of their sleep state in NREM sleep and 25% in REM. NREM sleep is divided into 4 stages. On an EEG printout, each stage has some unique traits in electrical conduction. The brain is more relaxed during NREM sleep than during wakefulness. Blood pressure is somewhat decreased and neural activity is less intense. The body is also more physically relaxed during these stages.
At the deepest stage of sleep, REM, the brain actually increases its activity. REM sleep is probably the most fascinating stage, as this is where we dream. During this stage, blood pressure and pulse will be close to or higher than waking levels. People cycle into REM sleep around every 100 minutes.
REM sleep is important for how we assemble and package up the memories of our day. If subjects experience significant sleep disruption, they often struggle with retained learning. This is especially important in our clinical work at CeDAR, as we are teaching our patients new things. If they experience poor sleep and disrupted stages each night, there may be some limitations as to how much information they can retain each day.
Some of the neurochemicals involved in the sleep cycle include serotonin, acetylcholine, dopamine, norepinephrine, and melatonin. It is not fully understood how these chemicals impact sleep, but the bulk of the research include animal models and human models, including those in which the chemicals are either deprived or excessive. For instance, low serotonin levels are associated with insomnia and sleep deprivation. This makes logical sense when we notice significantly depressed patients who struggle with insomnia. Low serotonin is a core biological issue with major depression.
Elevated levels of norepinephrine also increase wakefulness. Norepinephrine is a “fight or flight” chemical and is high when people are experiencing substance withdrawal or have histories of severe trauma. In some ways, this is a biologically protective mechanism. If you are in danger of being harmed (or at least perceive that you are…), you might need to stay awake to protect yourself.
Acetylcholine levels are also interesting as connected to sleep patterns. We know some about this as it applies to aging. Dementia conditions such as Alzheimer’s Disease are linked to changes in acetylcholine in the brain, hence we believe that elderly sleep disruption may involve acetylcholine. Decreased sleep as one ages is overall a normal process, so it’s important to distinguish age-related sleep decline with dysfunctional insomnia.
Melatonin is a unique chemical in the brain and is associated with sleep and patterns of daylight. It is also associated with our core body temperatures. For the brain to effectively fall asleep, there must be some slight decrease in temperature. The precursor amino acid for melatonin is L-tryptophan, which is high in such foods as turkey. It’s no wonder why many people will take a post-Thanksgiving nap!
Having some basic understanding of the neurochemicals connected to sleep is very useful in our clinical work. As people are struggling with substance withdrawal, trauma issues or depression, the chemical imbalances clearly disrupt sleep as well. This also lets us know to actively treat those conditions, as sleep can improve if we help the chemistry in the brain return to balance.
Like many conditions we treat at CeDAR, we approach insomnia with an appraisal determining if we should use medications, behavioral interventions or some of both. Many of our patients take sleeping medications, including such common prescriptions as trazodone or Seroquel. These meds are not addictive substances, but are not necessarily perfect for quality sleep restoration.
Sleep medications essentially slow down the brain and provide a heaviness, often through the transmitter histamine. Some medications inadvertently cause sleepiness due to their impact on histamine, such as the anti-allergy medication Benadryl. While all of these meds help people fall asleep, they may not necessarily promote quality sleep. Some medications, specifically the benzodiazepine class, can markedly interfere with the stages of sleep. This can leave someone feeling unrested despite receiving the desired number of hours of sleep.
Many sleep experts feel that the most powerful intervention to improve insomnia is a therapeutic approach called Cognitive Behavioral Therapy for Insomnia, or CBT – I. This is a stepwise therapy used to address all of the components of insomnia, including many that you might not consider. The overall goal of CBT – I is to help train the body and the brain to be a good sleep caretaker, such that sleep quality markedly improves.
Our upcoming articles will delve deeper into both the medication approaches for insomnia and the CBT – I protocol. As always, we are providing this same information to our current CeDAR patients, helping them gain greater understanding about the brain and quality recovery science.