Insomnia and Naturopathic Care

By Rachel Yeager

Rachel Yeager is a fourth-year naturopathic medical student at the National University of Naturopathic Medicine in Portland, Oregon. Her personal health and healing journey led her to career-switch from journalism to the pursuit of a naturopathic medical doctorate. She plans to use everything she has learned along the way to help others achieve optimal wellness and feel their best.

Do you have trouble sleeping? 

Sleep difficulty is common these days. In fact, up to one-third of people in the United States meet the criteria for insomnia disorder, meaning they have difficulty sleeping even in ideal circumstances. There are different types of insomnia and different ways insomnia can be categorized. Here are some of the categories:

1. Sleep onset insomnia, meaning a person has difficulty falling asleep

2. Sleep maintenance insomnia, meaning a person has difficulty staying asleep

3. Primary insomnia, meaning the insomnia exists independently of other health conditions

4. Secondary insomnia, depending on whether insomnia exists secondary to another circumstance or a medical condition such as an anxiety disorder.

5. Short term insomnia disorder, meaning the insomnia has been present for less than three months.

6. Chronic insomnia disorder, meaning the insomnia occurs more than three nights weekly and has been present for more than three months.
   
   

Causes of insomnia

There are many causes of difficult sleep. In a naturopathic healthcare approach, identifying the cause of an illness is extremely important. This is because naturopathic practitioners believe in an individualized approach and typically avoid using generalized, one-size-fits-all approaches. Once the cause of your insomnia is determined, your naturopathic doctor can create a targeted treatment plan customized for you. 

For example, if a patient were having trouble staying asleep because they were having racing thoughts in their head as they lay in bed, their treatment plan should look very different than that of a patient who is having trouble sleeping because they have to wake many times in the night to urinate. In this case, instead of prescribing both patients a sleeping pill, the first patient might benefit more from a plan that addresses their anxiety, and the second patient might benefit more from a plan that directly addresses their nighttime urination. 

The causes of sleep disturbance are numerous, but here are some of the most common causes:

• Cortisol (stress hormone) levels that are dysregulated, or out of balance
• Blood glucose (blood sugar) levels that are dysregulated, or out of balance
• Changes in levels of sex hormones, such as decreased estrogen in menopause
• Medications, such as those used to treat hypothyroidism
• Stress, anxiety or depression
• Chronic pain
• Altered circadian rhythm due to irregular work schedule or poor sleep habits
• Substance intake, such as coffee, nicotine and alcohol
• Aging, which can naturally shift sleep patterns 

Treatments and the Naturopathic Therapeutic Pyramid

Once the cause of difficult sleep is identified, naturopathic doctors can offer a wide range of therapies to treat the identified cause and improve sleep. Some of the modalities, or different categories of therapy, that can be used to treat insomnia include herbs, homeopathy, pharmaceuticals, hydrotherapy, dietary recommendations, lifestyle recommendations, and bodywork. 

Your naturopathic physician might also refer you to receive acupuncture, cognitive behavioral therapy, or see a sleep specialist. 

Naturopathic doctors follow the naturopathic therapeutic pyramid to determine what level of treatment to begin with. Naturopathic philosophy is to use the least harmful intervention first and ascend to more potentially harmful therapies as needed. The base of the naturopathic pyramid has the treatment goal of re-establishing the foundations of health and removing obstacles to cure. 

Re-establish the foundation so health and remove obstacles to cure

In the setting of improving sleep, foundational therapies might include establishing a rhythm of going to bed and waking at the same time, falling asleep before 10:00pm to maximize periods of restorative sleep, and conserving the bed for sleep and sex only. Removing obstacles would include limiting caffeine intake or stopping caffeine intake around noon, as well as avoiding synthetic blue light exposure after dark by limiting screen time or wearing blue-light blocking glasses. Removing high-sugar foods from the diet, especially sugary snacks before bedtime, is another example.

Stimulate the healing power of nature

The next step of the therapeutic pyramid is to stimulate the healing power of nature that resides within us all, the Vis medicatrix naturae. Sunlight exposure helps heal and re-align our bodies, and it allows our hypothalamus (brain) to set our internal circadian rhythm. This could be done by standing in direct sunlight or using a sun “happy lamp” for at least 10 minutes immediately upon waking. Meditation is also a healing exercise that strengthens our own life force within us. Meditating at night and in the morning may be recommended for improving sleep.

Support and nourish weakened or damaged organ systems

The next tier is to support and nourish weakened or damaged organ systems. Are you constantly on the go? Do you feel stressed out? Perhaps your adrenals are working in overdrive to try to produce enough cortisol to keep you going. Adaptogens such as ashwagandha and schisandra are a class of herbs commonly used to nourish adrenals and balance cortisol levels. Do you drive in busy traffic? Eat while you watch TV? Worry about meeting deadlines and making appointments? You might have sympathetic dominance, in which the “fight or flight” arm of your nervous system is overactivated, drowning out the parasympathetic “rest and digest” arm of your nervous system. Nervines, such as chamomile, skullcap and milky oats, are another class of herbs that support and restore the calming parasympathetic nervous system. They can be drunk as a tea, consumed in an herbal extract tincture, or taken as capsules.

Correct Structural Integrity

One step up the pyramid is correcting structural integrity. Visceral (organ-level) massage and craniosacral therapy (gentle hands-on therapy to move cerebrospinal fluid) are examples of therapeutic structural manipulations, although the most commonly thought of structural manipulation usually involves the spinal column. The spine runs along with the spinal cord, the main cord of nerves coming from our brain that branches and goes to our organs, arms, and legs, all the way down to our fingers and toes. Our body is a tightly woven network of nerves and muscles connecting to fascia which connects to other muscles, organs, bones, and even our spine. If even one vertebra of our spine is out of alignment, it might be putting pressure on nerves, or pulling on connective tissue that connects to our organs. This connective tissue also houses our blood vessels and our lymph, which drains waste from our body. By carefully moving a vertebra back into position, we might affect blood flow, relieve pressure on an organ and improve drainage of toxic waste. Adjustments can also relax any surrounding tense muscles, which can also improve sleep.

Prescribe Specific Natural Substances for a Condition

The next step in the naturopathic therapeutic order is to prescribe specific natural substances for a condition. Perhaps a patient has already completed the relevant prior steps and is still having trouble sleeping, or they need extra support from the get-go. An example of natural substances used in insomnia are melatonin, and recent research has found that doses less than 3mg, and more specifically doses in the 0.3-0.5 range, are most helpful for improving sleep when used about 30 minutes before the desired sleep time., Other examples of nutraceuticals are magnesium glycinate, which helps relax muscles and relax the body overall, and L-theanine, which is a calming amino acid. Nervines, which were previously mentioned as a way to calm the nervous system, are also used for sleep. Interestingly, the dose of the nervine determines its therapeutic benefit; smaller doses are used for a calming effect and larger doses are used safely for a sleeping effect.

Pharmaceutical Intervention

The second-to-last step is pharmaceutical intervention. Pharmaceuticals are considered higher-force interventions because they can have strong effects but often come with higher health risks. For example, Ambien is one pharmaceutical option used for insomnia, and some people experience sleep benefits from taking this powerful sedative. But in some people, Ambien can also cause dependence and dangerous behaviors such as driving while not awake. In naturopathic care, pharmaceuticals are reserved for appropriate circumstances. They are usually only first-line therapies when either the patient opts for them or the provider considers them necessary for the well-being of the patient, which typically occurs in more advanced stages of diseases, severe conditions, or emergencies. 

Surgical Intervention

The last step is surgery. Ideally, conditions that warrant surgery are prevented by following the previous therapeutic steps. But this isn’t always the case. One extremely rare example of a surgery done to improve sleep is removal of a pheochromocytoma, an adrenal tumor that secretes stimulating fight-or-flight hormones, often in sudden bursts and at inappropriate times, such as at bedtime.

As with everything, there are exceptions to the above-listed trajectory, but following the step-wise approach is often successful because each step builds a stronger foundation from which to move forward. Basic aspects such as diet, sleep, and movement impact all areas of the body and impact all conditions. Starting with these foundational, widely impactful aspects ensures you aren’t masking an underling problem that might be temporarily masked when you start treating symptoms. For example, if you are eating such a sugar-filled diet that your body is having trouble sleeping at night, perhaps you are headed down a path toward diabetes and altering your diet instead of masking your insomnia with an Ambien pill might ultimately be life-saving. Following a bottom-up approach serves as preventative medicine and also has the goal of reducing iatrogenic (practitioner-caused or treatment-caused) diseases.

Summary

Insomnia is a multi-factorial condition and identifying the cause of your specific insomnia is an important first step. Seeking naturopathic care for insomnia unlocks a large toolkit of therapeutic options. Working with a licensed naturopathic doctor to follow the therapeutic order might be a good starting place.