Chronic Primary Insomnia – Diagnosis, Evaluation and Therapy

Chronic Primary Insomnia - Diagnosis, Evaluation and Therapy
Chronic Primary Insomnia - Diagnosis, Evaluation and Therapy

 

Chronic Primary Insomnia - Diagnosis, Evaluation and Therapy
Chronic Primary Insomnia – Diagnosis, Evaluation and Therapy

Introduction:

The ancient sage Caraka describes sleep as “ when the mind including the sensory and motor organs is exhausted and they dissociate themselves from their objects, then the individual sleeps” (Ca. Su. 21/25) One can infer that loss of the ability to dissociate from the object of focus or lack of exhaustion (continued activity) will result in insomnia based on this definition of sleep.  He further goes on to state that “overwork, old age, diseases (especially those due to vitiation of vata), colic pain . . . . cause sleeplessness [and] some are insomniac by nature.” (Ca.Su 20/55-57). Vagbhata elaborates that the most effective insomnia treatment is “resorting to things which are comforting to the mind [and body].” (As. Su 7/66-68) Western perspective echoes both these sentiments and serves to sub classify sleep disorders to facilitate treatment. This review will explore the issue of insomnia from both the western and non-western perspective. The focus will be based on the definition afforded by Caraka, therapies suggested by Vagbhata peppered with Western thought in an attempt to demonstrate a valid integrative Ayurvedic/Western model of diagnosis and treatment.

 Definition

Many definitions of insomnia exist in western medical literature. Most authors will describe insomnia as difficulty initiating or maintaining sleep, sleep that is poor quality, trouble sleeping despite adequate opportunity and circumstances for sleep, or waking up too early.1 In addition, the definition of insomnia is expanded by the consequences of sleeplessness. Those being functional signs and symptoms observed during waking hours. The most commonly reported include concentration loss, memory impairment, daytime sleepiness which can result in errors or accidents, lack of motivation, mood disturbance and physical manifestations such as gastrointestinal symptoms and headaches.2 Ayurveda defines insomnia similarly  however will correlate the definition to dosa and dhatu disruption. Dr. Vasant Lad loosely defines insomnia as being the result of primarily vata vitiation leading to depletion of medo dhatu and hyperactivity in majja. He relates these to vishama agni. 3 While most insomnia appears to be related to vata vitiation he further describes insomnia types that can have other dosa features. Vata predominant is consistent with frequent waking with many dreams, pitta demonstrates difficulty initiating sleep often waking around 2 am, and kapha types wake early. Most of these descriptions center on clinical presentations that are related to secondary causes of insomnia and not primary. Both western and modern ayurvedic authors will additionally subclassify insomnia by chronology; either acute or chronic, and etiology; primary or secondary.4

Most clinicians accept the definition of acute insomnia as abrupt onset of sleeplessness with duration of less than one month. Chronic insomnia is further related to sleep disturbance of greater than one-month duration.5 Primary insomnia is defined by exclusion, i.e. there are no underlying causes creating sleeplessness. Those causes can be related to comorbid disease process, movement disturbances, genetic, metabolic, mood, environmental, behavioral, and iatrogenic factors. Any of these underlying factors would lead to the diagnosis of secondary insomnia. Much can be written about acute secondary insomnia and chronic secondary insomnia addressing the root causes. Treatment of the underlying primary pathology often leads to restoration of normal sleep patterns. Acute primary insomnia however, is oftentimes self-limited and patients rarely come to the attention of clinicians. More problematic for treatment is chronic primary insomnia. Caraka elegantly describes the latter patients as . . .”insomniac by nature.” (Ca.Su. 20/57). The focus of this paper will be on the challenging issue of chronic primary insomnia.

 History 

Most students of the classics remember the Greek god Morpheus as the god of sleep. His role was to act as an emissary of the god’s to induce or reduce sleep and manage dreams, often to comply with the god’s elaborate plans for man.6 From his name we get the well known drug Morphine, a potent narcotic. While the ancient Indian lore describes Urmya as the protectress of sleep little is written about her. The Mandukya Upanishad mentions sleep, dream and cognition in relation to achieving bliss and exploring the nature of Aum. In his commentary on this Upanishad, Swami Krishnanda speaks of sleep in a hallowed way, which appears to be one path to achieving bliss. One can infer then, that the limitation of sleep would lead to its opposite. Hence sleep is a necessary activity to reach Samadhi. He describes sleep as “(a time when) we are not aware of the world outside in the state of sleep because of the absence of vrttis or psychoses of the mind.”7  This passage implies that vrttis or psychoses of the mind lead to sleeplessness. The mind, therefore, may be one of the clear impediments to sleep while also its promoter, a clear paradox. The earliest recorded reference to insomnia per se, is in the ancient Gilgamesh, written some time during the 26th century BC. In it Gilgamesh becomes mortal in a transition from constant wakefulness to knowledge.8  Again it is the interplay of the mind with sleep that acts to prevent rest and in this case the transition is from insomnia to knowledge. In the Gilgamesh epic as in the Mandukya Upanishad, sleeplessness and sleep play in the gray zone between mortality and immortality, bliss and despair which almost implies a rhythmic counterbalance. This interplay and the role sleeplessness plays in obstructing the path to Samadhi or nirvana supports the volume of literary interest. It wasn’t until 1729 that Jean Jacques d’Ortous deMairan demonstrated scientific evidence of circadian rhythms and the role they play in human life.9 This subsequently led to the western understanding of sleep requirements according to biological order, which was known for millennia in Ayurveda as the diurnal variation of the dosas. These rhythms align the human with nature and may play a role in tipping the balance to soul attainment.

 Prevalence

Estimates of the prevalence of chronic primary insomnia varies with the population studied. Overall conclusions from the 2005 NIH State-of-the-Science Conference yielded a range of 8-24% prevalence. 10 If the strict DSM-IV criteria are applied to the definition of chronic primary insomnia the prevalence is closer to 6%.11 The NIH goes on further to describe certain populations that have increased incidence of chronic insomnia. These include female gender, advancing age and non-caucasian race. While the cause of the increased incidence of insomnia in these populations is not well defined one can surmise that in the older population loss of sleep and the daytime manifestations may be related to a decline in the functionality of sleep control systems in the brainstem. Interestingly insomnia in the female population is more common at puberty and menopause suggesting a hormonal etiology.12 Western medicine and Ayurveda agree on these prevalence values.

Etiology and Pathogenesis

Western medicine submits that chronic primary insomnia is idiopathic. This results in therapies based on signs and symptoms. Ayurveda however, can explain most chronic primary insomnia on the basis of dosa imbalances resulting in specific treatment algorithms. This is one point where western medicine and ayurveda deviate. Most investigators, both western and ayurvedic will admit that psychological and physiological studies suggest some form of “hyperarousal.” This is corroborated with measurements of daytime and evening serum cortisol/ACTH levels that elevate in the evening hours. Clinical findings also suggest a dysregulation of the reticular activating system which serves to regulate sleep and wake cycles. This dysregulation or hormonal imbalance results in increased heart rate, heart rate variability, and increase in whole body metabolism.13 Recent positron emission tomography (PET) studies support these findings with demonstration of elevated whole brain metabolism both during sleep and wakefulness and regional activation in affective and arousal centers during non-REM sleep.14  (figure 1: Demonstrates the anatomic distribution of increased blood flow and activity in the arousal centers during non-REM sleep in insomniacs) The findings also indicate lack of inhibition of brain wake centers during prodromal periods. While this is valuable information it does not address the issue of different presentations of sleep disorders. In a recent online discussion through Sify Health Dr. Yatin Patel, MD MBA indicates that while according to Ayurveda sleep is considered one of the pillars of life, the amount of sleep varies by dosa. He describes insomnia through the lens of Ayurveda as being vataja if it is related to poor sleep onset, pitta type if related to poor maintenance of sleep and kapha type if you wake up drowsy. This perspective can be married to the western view of a hyperarousal state especially in view of the physiologic and imaging evidence and is corroborated with patterns suggested by Dr. Lad with some variations.

Figure 1

1

  Diagnosis and Evaluation

Chronic primary insomnia is a diagnosis of exclusion. To that end all potential comorbid conditions need to be excluded before the diagnosis can be made. The history of the present illness should be thorough and is the cornerstone of evaluation. It should focus on the patient’s current symptoms, habits and patterns. Specific inquiry to the following should be undertaken:15

  • Sleep patterns
  • Specific habitual sleep behaviors
  • Variability in sleep timing
  • Emotional, physical and cognitive states around sleep
  • Exclusion of other sleep related conditions-snoring, restless legs, apnea
  • Daytime consequences
  • Comorbid medical conditions-Cardiac, CNS, renal, endocrine and digestive, especially conditions associated with chronic pain, breathing difficulty, and impaired mobility
  • Comorbid psychiatric conditions-anxiety states, bipolar, depression
  • Medications including non pharmacologic-beta agonists and antagonists, corticosteroids, stimulants, decongestants, antidepressants, statins, dopaminergic
  • Diet-alcohol, caffeine, nicotine

Based on the responses to the review the diagnosis can then be adjusted by inquiring as to an historical perspective and if there is a familial component. Once all comorbid conditions are effectively excluded can then the diagnosis of primary insomnia can be made and based on chronology acute or chronic. Certainly the lens of Ayurveda will inquire as to the same history however root cause can be ascertained as to the dosa imbalance leading to the insomnia, which will serve to direct therapy. A root cause analysis of the pattern of sleeplessness will create the framework for an accurate diagnosis. Vata pattern is generally related to abnormal sleep pattern and anxiety. Pitta pattern is generally related to poor sleep initiation and anger. Kapha pattern is generally related to difficult arousal that in strict terms in not classically insomnia but can result in similar daytime consequences as both Vataja and Pitta pattern. Despite the approach to pathogenesis and root cause analysis collection of additional data is useful in the diagnosis of this condition. Many authors suggest the use of a 2-week sleep diary, wherein the patient records patterns around the initiation of sleep, any events during the sleep period and feeling on waking. 1,11,13Sleep laboratories where subjects are observed during a sleep cycle often obtain EEG data for evaluation of alpha, beta and delta patterns which may also contribute information for the diagnosis. Some clinicians suggest the addition of brain imaging (either MRI or CT) to exclude the possible diagnosis of occult organic lesions.16 Once the diagnosis is established a therapeutic plan can be developed.

 Therapy

Western clinicians often treat acute forms of insomnia with pharmacological agents regardless of etiology and Vagbhatu reminds us that treatment should be “comforting to the mind” (As Su 7/68). The most common drugs currently approved by the U.S. Food and Drug Administration for treatment of insomnia includes eight  benzodiazepene receptor agonists (zaleplon, zolpidem, eszopiclone, triazolam, temazepam, estalzolam, quazepam, flurazepam) and one melatonin receptor agonist (ramelteon). The action of these drugs is primarily sedative with an amnesic component. They function to bind to the GABA type A receptors in the central nervous system. The choice of which agent to use is based primarily on the half-life of the drug, i.e. what is its ultimate duration of action. 17  While these drugs may be adequate for short term use their side effects and potential for abuse/dependence makes them unacceptable for long term therapy. In addition, they are often used without consideration of the root cause of the insomnia. For the treatment of chronic primary insomnia, drug therapy can be useful in “crisis” situations or as an initial plan, but does not address long term care. Alternative methods of treatment have been researched and include herbal remedies, massage, yoga, mind-body therapy (including meditation and acupressure).18,19 Herbal remedies that have undergone the most rigorous scientific study include valerian, kava, melatonin and L-tryptophan. Of these reviewed, the literature demonstrates mixed reports of success. All demonstrate some benefit over placebo in the quality of sleep with exception of valerian. The ambiguous evidence in the valerian studies may be in part due to study design and patient selection criteria.20  Melatonin has been very popular in the treatment of sleep disorders. Commercial melatonin is an analogue of pineal secretions, which appear to have a role in sleep and wake cycles. In the literature there are conflicting views of its efficacy. In an older paper Ellis and colleagues22 report no improvement in sleep or outcomes in their cohort of patients taking commercial grade melatonin at 8 pm. In a more recent article Wade, et al, reports a larger cohort in a well designed study23 that evaluated the efficacy of prolonged release melatonin (melatonin-PR). In this group, patients reported a significant improvement in the overall quality of sleep and subsequent next day alertness. The earlier study had some design flaws including small sample size and the latter study evaluated a prolonged acting melatonin rather than melatonin that was not designed for prolonged action. It seems that while the issue of melatonin remains somewhat controversial, the evidence points to value in its use, with minimal side effect. A review of herbal treatment of insomnia using oriental herbs from the Hong Kong Medical Journal,21 suggests the use of St. John’s Wort for sedation. In their study they find similar in vitro action as benzodiazepene agonists with receptor affinity for GABA.  Other anecdotes of herbals used for treatment of insomnia exist. One of the more popular is passionflower. David Wheatley has concluded that evaluation of the sedative effects of passion flower require further investigation as the current literature is inconclusive.24Of the remaining non-pharmacologic therapies acupressure, meditation and massage all demonstrate a positive effect on sleep quality in patients with chronic primary insomnia. One of the most interesting therapies for chronic primary insomnia proved to be Yoga. In a study undertaken in 2004 Indian researches stratified 120 members of an older age group (greater than 69) and demonstrated a statistically significant decrease in the time required to fall asleep, an increase in the total hours slept, and the feeling of being rested in the morning in patients undergoing a regular yoga practice.25 This yoga practice included 10 minutes pranayama, followed by 5 minutes “loosening”, 20 minutes asana (gentle vinyasa flow) 10 minutes of pranayama (brahmari, anuloma viloma) concluding with 15 minutes yoga guided relaxation.This practice was subsequently followed by lectures on yoga theory and ‘cyclic meditation’ taken from the Mandukya Upanishad. Interestingly a second cohort did not follow the Yoga routine but followed Rasayana Kalpa, which included Ashwagandha as its primary herbal (additional herbs included Amalaki, bala, pippali). The group on the herbal remediation only did not report improvement in sleep. Another interesting proposed treatment is the use of shirodara. At the APHA annual meeting 2007 Dr. Sivarama Vinjamury, MD, MAOM presented a case study26 on the use of Ayurvedic shirodara for the treatment of insomnia. In this case study Dr. Vinjamury demonstrates that after 5 days of treatment with Brahmi oil the patient had moderate improvement of his insomnia without side effects. He also indicates that prior researchers have demonstrated positive relaxant effects of shirodara which include suppression of sympathetic tone, decreased heart rate, and reduction in anxiety. While there is ongoing research in non-pharmacologic treatment for insomnia, the literature is absent clear scientifically documented treatments for specific dosa.

Intuitively one could conclude that if a patient were suffering from chronic primary insomnia that all the above therapies might treat the symptoms adequately without addressing the root cause. In a single online blog Busra Kafeel (OnlyMyHealth 9/20/2011) presents a “cure” for vata type of insomnia. This author combines herbal remedies, lifestyle changes, and shirodara which, the author argues can “cure” insomnia. Despite the claim the blog is absent scientific data. This however, implies that combined approach might be the most efficacious. Intuitively one can surmise the appropriate treatment for dosa diagnosed insomnia is to use specific dosa pacifying diet, lifestyle, herbs and spices. However, there is no supportive evidence with valid scientific backing in the current literature. To have the final word on this issue Dr. Vasant Lad in his seminal work The Complete Book of Ayurvedic Home Remedies (pp.211-12) suggests warm milk, cherries, tomato juice as well as chamomile tea, warm oil massage and hot bath as treatment for insomnia. In an article from Ayurveda Today27, Dr. Lad emphasizes ambiance (quiet/darkness), physical position (lying on the right side), evening abhyanga (bhringarga oil) prior to retiring. He additionally suggests a “so” “hum” focused meditation to create a peaceful mind. He closes with herbal formulas for each of the dosa imbalanced etiologies of insomnia. For vata he recommends dashamula, ashwagandha, tagara, and jatamamsi. For Pitta he suggests shatavari, guduchi, jatamansi and shankha pushpi. For kapha he suggests punanarva, sarasvati, chitrak and tagara. These should be taken ½ teaspoon an hour before bed with warm milk. If we dissect the component herbs, their virya and vipaka, it is clear that each combination is designed to pacify the respective dosa. While there are no references for his therapeutic plan one can assume that millennia of experience can speak for themselves.

Non-medicinal treatments for insomnia are abundant. Ample research has been done on formal meditation practice. For insomnia sufferers meditation alone may not be enough to treat the chronic sleeplessness. Meditationwhen combined with cognitive-behavioral therapy demonstrates positive responses to insomnia reduction when measured by the insomnia severity index. 28 This has been documented in a well designed recent study. Mindfulness Based Stress Reduction (MBSR) originally described by Jon Kabat Zinn and colleagues in 199329, which centers on non-judgmental present awareness focus, is demonstrated to be synergistic with cognitive therapies that challenge dysfunctional thought patterns (anxiety over insomnia for example) and maladaptive behaviors. This makes intuitive sense since the principles of MBSR are congruent with the goal of reducing hyperarousal.  Those principles include letting go, acceptance and non-striving. Minor flaws in the study include a somewhat biased population (students at Stamford University), small sample size (N=30) and poor to moderate compliance with meditation (none could complete 30 minutes of complete meditation). Despite the study limitations, it does suggest a positive impact on sleep patterns with integrated therapy.

 Conclusion

Understanding the etiology of insomnia can allow the clinician a reasonable tool for treatment. While chronic primary insomnia remains a problem for 6% of the U.S.  population, management can be achieved. Through the use of herbal, lifestyle, yoga and meditation techniques combined with patient compliance to reduce stimulants and stress, healthy sleep patterns can be restored. Benzodiazepine agonists may play a role in “crisis” or the initiation of therapy. This brief review of the literature enforces the concept that in the absence of an underlying root cause ayurveda can provide clarity of etiology. In this way integrating ayurveda into the western model can be a great advantage to deliver high quality multimodality care and create an individualized therapeutic plan. In the end, managing sleep disorders in a high stress culture is challenging and the physiology even after many years of research remains poorly understood.  If we can, as Caraka suggests, dissociate the mind from the object of attention then sleep will prevail. Turning “off” the activity of the intellect is the goal. William Dement, the co-discoverer of REM sleep patterns, in a National Geographic article30 is quoted as saying that “the only reason we need to sleep that is really, really solid is because we get sleepy.” That is of course, if you are not insomniac.

References 

  1. Roth T, Insomnia: Definition Prevalence, Etiology and Consequences. Journal of Clinical Sleep Medicine. 2007; August 15, 3(5 Suppt), S7-10.
  2. Ibid
  3. Lad V, Textbook of Ayurveda, Fundamental Principles. Vol 1, The Ayurvedic Press, 2002, pp 91, 138, 163.
  4. Pettit L et al, Non-pharmacologic management of primary and secondary insomnia among older people: review of assessment tools and treatments. Age and Ageing 2003; 32: 19-25
  5. Ibid
  6. Ovid, Metamorphoses, Book XI
  7. Swami Krishnanda,.The Madukya Upanishad. The Divine Life Society Publisher, 1996, pp 70-73.
  8. Steger B, Insomnia: A Cultural History (review). Bulletin of the History of Medicine. Volume 83, Number 2, Summer 2009, pp. 385-386
  9. Dement W. The study of human sleep: a historical perspective. Thorax 1998; 53: S2-S7
  10. Sleep: National Institutes of Health State of the Science Conference Statement of Manifestations and Management of Chronic Insomnia in Adults; June 13-15. 2005. Pp. 1049-57
  11. Roth T, Insomnia: Definition, Prevalence, Etiology and Consequences. Journal of Clinical Sleep Medicine. 2007; August 15, 3 (5 Suppt), S7-10
  12. Ibid
  13. Buysse D. Chronic Insomnia, Am. J. Psychiatry. 2008 June; 165(6): 678-686
  14. Nofzinger E et al. Functional Neuroimaging Evidence for Hyperarousal in Insomnia. Am J Psychiatry 2004; 161: 2126-2128
  15. Spielman, A. J., and M. W. Anderson. The clinical interview and treatment planning as a guide to understanding the nature of insomnia: the CCNY Insomnia Interview. Sleep Disorders Medicine: Basic Science, Technical Considerations, and Clinical Aspects. Edited by Chokroverty S. Boston, Butterworth-Heinemann (1999): 385-416
  16. Personal correspondence
  17. Ibid 13
  18. Pearson N, et al. Insomnia, Trouble Sleeping, and Complementary and Alternative Medicine. Arch Intern Med. 2006; 166(16): 1775-1782
  19. Sarris J, Byrne G. A systematic review of insomnia and complementary medicine. Sleep Medicine Reviews, April 2010, pp 1-8
  20. Lehrl S. Clinical efficacy of kava WS 1490 in sleep disturbances associated with anxiety disorders. Results of a multicenter, randomized, placebo-controlled, double-blind clinical trial. J Affect Discord. 2004; 78: 101-10
  21. Wing YK. Herbal treatment of insomnia. Hong Kong Medical Journal, 2001; 7: 392-402.
  22. Ellis CM. Melatonin and Insomnia. Journal of Sleep Research. March 1996 Vol. 5, Issue 1, pp. 61-65
  23. Wade AG et al. Efficacy of prolonged release melatonin on insomnia patients aged 55-80 years: quality of sleep and next-day alertness outcomes, Current Medical Research and Opinion, 2007, Vol. 23, No. 10, 2597-2605.
  24. Wheatley D. Medicinal Plants for Insomnia: A review of their pharmacology, efficacy and tolerability. Journal of Psychopharmacology. July 2005, Vol 19, Nov. 4, 414-421
  25. Manjunath NK, Telles S. Influence of Yoga and Ayurveda on self-rated sleep in a geriatric population. Indian J Med Res, May 2005, pp 683-90
  26. Vinjamury SP, Ayurvedic shirodara treatment for insomnia: A case study. Presentation at 135th annual meeting APHA, November 3, 2007
  27. Lad V. Ayurveda Today. Summer 2011, Volume 24, Number 1, pp 215-224.
  28. Ong J, Shapiro S, Manber R. Combining Mindfulness Meditation with Cognitive-Behavior Therapy for Insomnia. Behav. Ther., 2008 June; 39(2): 171-182
  29. Miller J, Fletcher K, Kabat-Zinn J. Three Year follow up and clinical implication of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General Hospital Psychiatry. Vol 17(3), May 1995 pp192-200
  30. Max DT. Secrets of Sleep. National Geographic Magazine. May 2010.

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