Insomnia? Hyperarousal disorder?

Hyperarousal disorder or generally being tightly wound causes sleep and anxiety disorders.

Underlying stress or just individual tendencies–still very troublesome for many.

Many of the jail inmates I supervise claim sleep disorders and anxiety. No big surprise, but the general population suffer too, most primary care physicians prescribe anxiolytics and hypnotics a lot.

People in modern life are on anxiety meds and hypnotics. Hard working people are tired when they go to bed.

So exercise is good for blood pressure, heart, and brain.

Anxiolytic and Hypnotic Drug Use Associated With Mortality
Research · March 01, 2014

BMJ : British Medical Journal
Effect of Anxiolytic and Hypnotic Drug Prescriptions on Mortality Hazards: Retrospective Cohort Study
BMJ 2014 Mar 01;[EPub Ahead of Print], S Weich, HL Pearce, P Croft, S Singh, I Crome, J Bashford, M Frisher

In this retrospective, cohort study with a mean follow-up of 7.6 years, physical and psychiatric comorbidities were higher in patients prescribed anxiolytic and hypnotic agents. In addition, anxiolytic and hypnotic drug use was associated with overall mortality, in a dose-response manner.

The authors note that the results are limited by the observational nature of this study; however, the results suggest that anxiolytic and hypnotic drug use is significantly associated with an increased risk of mortality.

1 Expert Comment

Primary Care

David Rakel MD, FAAFP

Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study

This study reminds us of the potential dangers of overusing pills to treat a multi-faceted condition such as insomnia.

Let’s focus on benzodiazepines, which are associated with the highest correlation of death in this study. They work well in helping to knock the patient unconscious, but we know that they are habit-forming, reduce the amount of time spent in deep rapid eye movement sleep, and are associated with increased risk of death. This is an example of how just treating the symptom can worsen the overall health of the host. The former is quick, economically rewarded (see more patients in less time), straight forward, and easy. The latter is grey, takes time, and rather complex. The in-and-out, throughput model of primary care is potentially harmful, but the relationship-centered care that recognizes the unique individual over time is healing.

This study shows that regular use and use of more than 1 hypnotic drug at a time is more dangerous than periodic use. So how can we most effectively treat the circadian rhythm imbalance?

Rubin Naiman, PhD is a psychologist sleep expert who wrote the chapter on insomnia for a medical text I edit. He introduced me to the growing literature on how poor sleep is often related to hyperarousal. He states,

“Chronic cognitive-emotional hyperarousal is associated with elevated metabolic rate, sympathetic over-activation, and chronic inflammation. Hyperarousal may be understood as circadian alertness (wakefulness) that has gone awry and overrides both normal sleep drive and the excessive daytime sleepiness often seen with chronic insomnia.”

So how do we treat this sympathetic hyperarousal? Strong evidence supports cognitive behavioral therapy for insomnia (CBT-I). This encourages self-reflection and learning from the symptom. You can also explore stress reduction, early day aerobic exercise, and meditation. One of my favorite tools to try before prescribing the “knock-out” drugs is a new age, counting sheep-like technique called mindfulness sleep induction. Give it a try.

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One response to “Insomnia? Hyperarousal disorder?

  1. Nothing can be done about the period of the circadian rhythm, which is determined by metabolic rates, which are in turn genetically encoded. It is good that people are beginning to notice metabolism; ironically, medical doctors take better note of it than chronobiologists, who are captivated by the bunk theory of genetic regulation.

    The endogenous rhythm that sets in in isolation from sunlight varies too much for it to be properly called circadian. It becomes circadian due to light-induced synchronisation, in which melatonin plays a key role. An alarm clock does it, too, in a brutal and inefficient sort of way (say thanks to the medieval monks who invented the alarm clock so they could do their stupid rituals on time).

    Whatever the nature of synchronisation to day period, comes at a cost, and the cost varies with the quality of ambient light and the person’s free-running clock period. Entrainment is easier when the endogenous period is longer, rather than shorter, than 24 hours. The greater the difference, the costlier it is to maintain entrainment, and I posit that no effort should me made to synchronise a daily deviation of more than a couple hours. It is going to be unhealthy in any case, whatever the method. People so affected should consider a change of occupation if their career depends on circadian timing.

    Another bit of advice: don’t fret about the loss of sleep. Apart from real, neurological sleep disorders, sleep-loss anxiety is largely artificial — it is caused by the fear of consequences of not sleeping “at the right time”, rather than the peculiar sleep pattern you may have at the moment. Sleep when you’re tired of work, not when the wall clock shows bedtime. Similarly, wake up when you’re tired of sleeping. It’s all right if that sets you on a 30-hour day. You’ll be more productive and happier that way.

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