by Dr. Bill Rawls
Desperately needing and wanting to fall asleep but not being able to let go of conscious awareness is a frustrating experience. Tossing and turning, you wrestle with churning thoughts into the night. Every hour that slides by carries you farther and farther from achieving the rest you need to get through the next day. Sometimes, that’s the worst part — anticipating how terrible you’ll feel tomorrow. You know, because you’ve been there before.
For many people struggling with a chronic illness such as fibromyalgia, chronic fatigue syndrome (CFS), or chronic Lyme disease, this is typical of how many nights unfold. The tug-of-war with stealth microbes that typifies these illnesses generates inflammation in the brain and tissues of the body — you can’t sleep well if your brain and body are on fire. What’s more, the stress associated with being chronically ill sends the sympathetic nervous system — the part of the nervous system associated with the “fight or flight” response — into overdrive. In fact, sympathetic overactivity is the root cause of most cases of sleep dysfunction.
Sometimes, sleep dysfunction is the primary factor that precipitates chronic illness by wearing down the immune system and leaving it vulnerable to microbes and other system disruptors. Just as often, however, the stress and inflammation associated with chronic illness precipitate sleep dysfunction, too. Either way, the fact that you’re not getting enough restorative shuteye is impeding your recovery.
Ultimately, restoring normal sleep should be priority #1 on the list of things you can do to boost your recovery. The merry-go-round of sleepless nights and stress-filled days is a vicious cycle that must be broken for you to move forward. No matter what type of chronic illness you are struggling with, following the guide below will provide everything you need to know to make sleep restoration a central player in your healing process.
How Normal Sleep Happens
The first step in understanding why you can’t sleep is understanding how normal sleep happens. For most creatures, sleep is tied to the light and dark cycles of the earth and sun, but every creature on earth sleeps a little bit differently.
In humans, sleep is governed by two primary forces: circadian rhythm and sleep pressure. These two forces are independent but intimately tied together. Disruption of either one can keep you awake at night. Let’s take a closer look at them.
Sometimes called a “body clock,” circadian rhythm is the continuous ebb and flow of changing physiologic processes between sleeping and waking hours. It’s regulated by an internal clock located in the brain and led by cortisol, one of the primary hormones produced by the adrenal glands.
Cortisol mobilizes resources of the body to meet the demands of an active day. In the morning, rising cortisol levels lead a surge of other stimulating hormones that wake you up and get you going. In effect, cortisol revs your engine.
All wakeful activities are affected by cortisol. To energize muscles, the brain, and other vital functions in the body, cortisol stimulates metabolic functions. Increased metabolism raises body temperature — typically, core body temperature rises through midday, peaks in the late afternoon, and then starts to decline until about two hours after sleep onset, when it begins gradually rising again for the morning.
In the evening, cortisol drops and your waking activities quiet down. As your core temperature starts to decline and your metabolism slows, the body begins the process of resting and repairing itself.
Under natural circumstances, the onset of darkness stimulates secretion of the peptide hormone, melatonin. Melatonin initiates a tide of other hormones, including GABA, serotonin, dopamine, and more, that flow into the brain and trigger sleep. While you sleep, melatonin secretion recedes, and the morning light brings the flow of the hormone to a halt.
Adenosine and Sleep Pressure
Because sleep is so important for survival, the body also relies on a second, independent mechanism for promoting a good night’s rest — the buildup of a chemical compound called adenosine. Throughout the day, adenosine accumulates in the tissues of the brain where it binds to adenosine receptors and slows nerve cell activity.
One noticeable side effect of this binding process: Drowsiness. The longer you stay awake, the more adenosine builds up until not sleeping is nearly impossible. This effect is called sleep pressure.
Interestingly, physical activity is one of the most important promoters of adenosine accumulation in the brain. The more physically active you are through the day, the greater the buildup of adenosine and the stronger the sleep pressure will be in the evening.
The only way to clear adenosine from the brain is by sleeping. The better you sleep, the more adenosine is cleared, and the more awake and alert you will feel the next morning. If you’re still dragging at 11:00 in the morning, take that as a sign you didn’t clear enough adenosine the night before.
How Stress Keeps You Awake At Night
As I mentioned earlier, overactivity of the sympathetic nervous system is at the very core of most sleep problems. Here’s how stress plays into that.
The sympathetic nervous system is the body’s alert mode. During a stressful event, the brain stimulates secretion of adrenaline from the adrenal glands. Adrenaline primes the body for confrontation or quick getaway by increasing alertness and quickening reflexes. It also suppresses the urge to sleep by directly blocking sleep pressure associated with accumulation of adenosine.
While this natural defense mechanism might save your life in an acute emergency — say, by bolting you awake and kickstarting your response to a fire alarm at 3 am — longterm secretion of adrenaline can make a night of restful sleep difficult to come by. And that’s precisely what happens when the body is chronically stressed and the sympathetic nervous system goes into overdrive.
Sustained secretion of adrenaline due to nonstop daily stress (think: deadlines, tax season, relationship strife) not only disrupts sleep by suppressing sleep pressure, it also disrupts circadian rhythm by affecting cortisol secretion. Cortisol has a direct relationship with adrenaline: when adrenaline levels are elevated, cortisol stays elevated too in order to mobilize the body’s resources to keep up with extra demand created by stress. Elevated cortisol keeps the brain alert and disrupts the normal tide of hormones that initiate sleep.
When your sleep is disrupted night after night, the body starts breaking down. This creates more stress and drives your sympathetic nervous system even harder, generating that vicious, all-too-familiar cycle of being totally exhausted yet unable to fall or stay asleep.
Why Chronic Illness + Sleep Dysfunction Go Hand in Hand
Beyond the everyday stress of modern life, chronic illness adds multiple layers of stress factors — each of which contributes further to the sympathetic overactivity that drives sleep dysfunction. Though restful sleep is the one thing that could accelerate your recovery more than any other thing, capturing even an occasional good night’s sleep can be elusive. Here are the top five contributing factors:
1. Stealth Microbes and Chronic Low-Grade Inflammation
The evidence is mounting that stealth microbes such as mycoplasma, chlamydia, borrelia, bartonella, Epstein-Barr virus, and many others, play a central role in many chronic illnesses, including fibromyalgia and CFS,, as well as chronic Lyme disease. Immune dysfunction that results from the tug-of-war between the immune system and microbes that are deeply embedded in tissues generates low-grade inflammation throughout the body and also in the brain. The stress caused by chronic inflammation sends the sympathetic nervous system into overdrive, disrupting the normal tide of hormones and neurotransmitters associated with sleep.
2. Digestive Dysfunction
Chronic illness and digestive dysfunction often go hand in hand. The immune dysfunction associated with chronic illness increases susceptibility to digestive problems, but it’s also important to point out that refined food products are generally at the root of gut issues.
Eating excessive carbohydrates stimulates overgrowth of “bad” bacteria (dysbiosis) that feed on starch and sugar, which damages the intestinal lining. That allows inflammatory foreign proteins to “leak” into the bloodstream, a condition called leaky gut syndrome.
Bad bacteria also produce stimulating chemical substances, called amines, that cross the gut-blood barrier into the bloodstream. The resulting cycle of whole-body inflammation compromises the blood-brain barrier, allowing these inflammatory substances to leak into the brain — which in turn drives sympathetic overactivity and sleep dysfunction even harder.
3. The Stress of Being Sick
Chronic illness compounds everyday stress. Simple tasks, such as going to the grocery store, paying bills, or house cleaning can become overwhelming. Add financial constraints associated with compromised ability to work, and navigating life can seem impossible. The lingering uncertainty of chronic illness — not knowing how you’re going to make it through today, much less the next one — drives up adrenaline levels, disrupts circadian rhythm, and adds to the challenge of getting a good night’s sleep.
4. Toxic environment
Everyone on the planet is exposed to chemical and physical substances that have the potential to be toxic. Though exposure is often not significant enough to affect healthy people, individuals struggling with chronic illness are especially sensitive.
Take caffeine, for instance. Nearly ubiquitous in beverages of every variety, caffeine inhibits sleep pressure by interfering with the buildup of adenosine, much like adrenaline. And many people struggling with chronic illness take drugs that inhibit sleep. The list includes many antidepressants, heart medications, decongestants, and stimulants. Even sleep medications, once someone is habituated to them, inhibit natural sleep.
Beyond the toxins we knowingly expose ourselves to are the more insipid environmental ones. For instance, chemical toxicants found in air pollution and residues of pesticides and herbicides in food are stimulating and can disrupt sleep. Artificial lighting and EMF radiation can also have a negative effect on sleep.
5. Lack of Physical Activity
If all that wasn’t enough, chronic illness robs you of the one thing that might help override sympathetic overactivity and allow sleep to happen — increasing your level of physical activity. Inflammation associated with a chronic illness makes it uncomfortable to move. Pushing through the pain just increases the inflammation, making regular physical activity a tall order. Many people stricken with myalgic encephalomyelitis/chronic fatigue syndrome have trouble moving at all. Though it’s sometimes necessary to postpone physical activity until after you’ve reached a certain level of recovery, any amount of movement you can manage contributes to releasing tension associated with sympathetic overactivity and promoting accumulation of adenosine.
Natural Remedies for Sleep and Stress
Herbal therapy is one of the easiest and safest things you can do to improve your sleep and fast-forward your recovery. Herbal supplements and other natural therapies work by balancing neurotransmitters and hormones disrupted by sympathetic overactivity. Some are better for countering sympathetic overactivity during the day; others are best used for promoting natural sleep at night.
Though not as potent as drug therapies, a balanced regimen of herbs (when combined with good sleep practices) can be a powerful force in restoring normal restful sleep — without the high potential for side effects and habituation that are so prevalent with any drug therapy. Here are the ones I recommend most.
Ideal for daytime use, ashwagandha is a soothing adaptogen that promotes calm without causing sedation. It works by normalizing adrenal functions, including the production of both adrenaline and cortisol, by balancing the the hypothalamic-pituitary-adrenal axis, better known as the HPA axis. Ashwagandha also supports normal thyroid function and is known to promote optimal cognitive function. Potent antioxidants in the herb reduce inflammation in the brain and body.
For maximum benefits, ashwagandha is best complemented by other calming herbs like l-theanine, an amino acid found in green tea. L-theanine counteracts excitatory neurotransmitters in the brain, thus restoring balance when the brain is in an over-excited state. It also offsets the effects of caffeine. This combination of herbs is typically taken in the morning to counteract daytime stress, but the dose can also be repeated in the evening.
3. Tart Cherry Extract
At night, a low dose of melatonin can be beneficial for complementing natural melatonin levels that have been suppressed by artificial light and chronic illness. Tart cherries are a good natural source of trace melatonin, plus they provide potent antioxidants to reduce inflammation. High levels of supplemental melatonin (anything >1 mg) are disruptive to your biological clock and should be avoided.
4. Magnesium Glycinate
Magnesium supplements are beneficial for releasing tension. Several processes in the body, including muscle contractions, depend on a balance of calcium and magnesium: Calcium is an activator, and magnesium is a deactivator. Many people are low in magnesium and magnesium supplements can restore balance, allowing normal deactivation to resume. Magnesium glycinate is the best-absorbed form of magnesium and has the lowest incidence of loose stools. Glycinate acts as a calming agent as well.
5. CBD Oil
Symptoms of pain and inflammation are strong inhibitors of restful sleep — they also fuel sympathetic overactivity. One of the best options for moderating pain is full-spectrum CBD oil from hemp. CBD oil is also beneficial for relieving anxiety and improving sleep associated with sympathetic overactivity. Unlike medical marijuana, CBD oil does not cause euphoria, it has a low incidence of side effects, and it’s not associated with habituation with prolonged use. It is an excellent complement to the before-mentioned herbs and natural therapies. CBD oil can be taken during the day and also in the evening before bedtime.
6. Antimicrobial and Immune-Modulating Herbs
For any chronic illnesses associated with chronic immune dysfunction and stealth microbes, a comprehensive regimen of antimicrobial and immune modulating herbs should be central to any recovery effort. The appropriate herbs not only suppress stealth microbes deep in tissues, but they also reduce inflammation and boost immune system functions. Reducing inflammation is essential for calming your brain and getting up moving again. Ultimately, this part of the solution must be in place to restore normal sleep.
- Bacopa: Native to India, bacopa has been used for thousands of years to treat sleep disturbances and anxiety. It specifically calms an overactive nervous system, plus use of bacopa has been shown to offer enhanced cognitive function in children with ADD, college students during exam time, and elderly dementia patients in controlled studies.
- Passionflower: If you’re looking for an herb that offers both muscle-relaxing and sedative properties, passionflower has long been used for both. It has a reputation for restoring restful sleep without causing a next-day hangover.
- Motherwort: For people who find themselves awake and wide-eyed in the middle of the night, motherwort may be especially helpful. Traditionally used for relieving palpitations associated with menopause, PMS, and general nervousness, motherwort offers sedative properties and helps restore normal sleep. It has been noted to be particularly beneficial for those frustrating 3am awakenings.
Though not as potent as drugs or some other herbs, taking this trio will likely be all you need to enjoy a restful night’s sleep if you have taken steps during the day to reduce sympathetic overactivity and build up sleep pressure.. But on certain occasions — after a particularly stressful day, or when symptoms of chronic illness are especially pronounced — you may need herbs with more potent sedative properties to override the disrupted neurotransmitters associated with severe sympathetic overactivity (even when you don’t have enough sleep pressure built up). An effective combination includes kava, corydalis, California poppy, and jujube seed. But remember: With potency comes increased risk of side effects such as next-day sedation and potential for habituation — though none of these herbs are as potent as prescription drug therapies.
Break the Cycle of Sleep Dysfunction
Ultimately, to restore normal sleep, you’re going to have to address the underlying factors that are driving sleep dysfunction. If stealth microbes are at play, antimicrobial and adaptogenic herbs can go a long way toward reducing the inflammation and chronic dysfunction influencing sympathetic overactivity. But there’s more work to be done that herbs can’t necessarily provide.
Thankfully, there are several things you can control to help you get your sleep back on track. Yes, what you do at bedtime matters for setting the stage for normal sleep to happen, but so does how you go about the rest of your day. Here’s what you can do to get things moving in the right direction:
During the Day
Your daily goal should include minimizing buildup of adrenaline and sympathetic overactivity through the day and building sleep pressure associated with the accumulation of adenosine. Take the following steps to prevent your nervous system from kicking into overdrive.
1. Monitor tension. The best indicator of sympathetic overactivity is physical tension. Signs of tension include tightness in the shoulders and neck, rapid shallow breathing, and a high pulse rate. Tension tends to build through the day like a thunderstorm, so making an effort to calm the storm before it becomes a tempest will help you get a better night’s sleep.
Learn to recognize mounting tension so that you can take steps to release it. Slowing your breathing to a relaxed pace is one of the best ways you can release tension. Gentle yoga or Qigong practices for short intervals several times during the day is also a great way to release built-up tension.
2. Don’t go looking for extra stimulation. Make a priority list of what you think you can accomplish during the day, and avoid stressing over anything else. Focus on problems that are within your ability to solve. Avoid unnecessary stimulation, such as exclamatory news media or entertainment, especially in the evening hours.
3. Be as active as you can. Physical activity calms the sympathetic nervous system and increases sleep pressure by promoting the buildup of adenosine in the brain. That being said, excessive physical activity promotes inflammation, which can hold back your recovery and cause discomfort that keeps you awake at night. The balance of the right amount of physical activity is different for every person.
To find your sweet spot, start slow and build up with low-impact activities like walking. If walking isn’t practical, start with gentle yoga, or even better, the ancient Chinese movement arts of Qigong or tai chi. Any movement counts — kitchen work, cleaning the house, gardening, and working in the yard are other options. Gradually increase the level of activity each day as your recovery progresses.
4. Take a midday nap. Make a midday nap or meditation a regular habit. Even nodding off for a few minutes normalizes stress hormones built up during the day. Most people who are able to nap regularly during the day sleep better at night. However, an extended nap during the day reduces the buildup of adenosine for sleep at night, so you’ll want to limit your afternoon snooze to 15-30 minutes, and do it before 3 pm.
5. Minimize or eliminate caffeine. Caffeine locks you into the cycle of poor sleep. It works by suppressing sleep pressure. If you’re having sleep difficulties, the last thing you want is any caffeine present in your brain during the night. At least a quarter of the dose of caffeine you consumed in the morning, however, is still hanging around at bedtime.
As a general rule, coffee has the most caffeine, black tea is next on the list, and green tea typically has the least of the three. If you decide to quit caffeine, wean slowly to prevent withdrawal symptoms (headache, fatigue). To replace your coffee habits, green tea is a good choice thanks to its l-theanine, which helps block the detrimental effects of caffeine.
6. Eat healthfully. High-carbohydrate, processed foods lead to insulin resistance and overgrowth of bad bacteria in the gut, both of which contribute to sympathetic overactivity. The best diet for good sleep is rich in vegetables, fruit, healthful fats, and nutritious protein sources.
My golden rule for healthy eating is targeting a dietary goal of more than 50% fresh vegetables and less than 5% processed or packaged foods. Avoid heavy evening meals — a light supper before 6 pm in the winter and before 7 pm in the summer is ideal. But you shouldn’t go to bed hungry either — a banana is an excellent evening snack if you need to curb your appetite.
7. Be wise about medications. Many medications inhibit normal sleep. The list includes steroids of any type, beta-blockers for lowering blood pressure and treating heart conditions, some anticonvulsants, stimulants for weight loss and ADD, and selective serotonin reuptake inhibitors (SSRIs) used for depression and anxiety. Sleep medications, once tolerance and habituation have occurred, are notorious for causing chronic sleep dysfunction. If you are taking a drug that you think may be contributing to sleep dysfunction, work with your healthcare provider to either reduce the dosage or switch to another medication.
You’ve had all day to think about things. Evening is the time to wind down and set your cares aside for the day. If you start purging the stress of the day in the late afternoon or early evening, your brain is freed up to move toward a state of accepting sleep.
1. Enjoy quiet conversation, music, or reading. For reading material, choose something that isn’t stimulating or thought-provoking. Heated discussions or thoughts about the stress of the day will keep you awake all night. It’s better to let it go or leave it until the next morning. Though this lifestyle may sound boring, the tradeoff is getting back to normal sleep patterns!
2. Avoid lighted screens after 9 pm. Computer, tablet, cell phone, and television screens are notorious for suppressing melatonin and blocking initiation of the sleep. Blue-light filters can help, but the flickering light of the screen itself still keeps the brain alert. You’ve got 14 hours of daytime to soak up information from screens — take a break in the evening and enjoy some other relaxing activity.
The same goes for artificial lighting. LED lights may be saving the planet, but they wreak havoc on sleep. Have a bedside lamp with a single soft white low light bulb. After the sun goes down, use just enough light to get by.
3. Unwind with gentle movement. Vigorous exercise during the day is great for sleep, but it should be avoided after 8 pm. If you need to work out pent up muscle tension immediately before bedtime, use gentle stretching routines such as yoga or Qigong. Regular practice of meditation is also effective for purging built up adrenaline.
4. Take a hot bath. Soaking in a hot bath dilates blood vessels in the skin, so when you get out of the tub, water evaporating from your skin accelerates cooling, which can help you fall asleep. A hot bath also relaxes muscle tension and is a great way to unwind.
5. Skip the nightcap. Alcohol initially is a sedative, but the metabolites are stimulants. Beer and wine also contain chemical byproducts of fermentation called amines, which are very stimulating and will inhibit sleep. Expect to be awake about three to four hours later if you consume alcohol in the evening. This may surprise many people, but alcohol, in any amount, always disrupts normal sleep. After your sleep improves, you can return to an occasional glass of wine, beer, or light cocktail.
6. Minimize bathroom trips. Bladder irritability with frequent urination is sometimes a sleep disruptor. If this is the case, minimize all liquid intake before 6 pm. Empty your bladder immediately before going to bed. If frequent awakenings due to urination frequency remain a persistent problem, ask advice from your healthcare provider.
While You Sleep
Good sleep requires a comfortable and neutral environment that promotes a state of calm. The more you can control your sleep environment, the better you will sleep at night.
1. Consider your mattress. A comfortable mattress is essential for a good night’s sleep. If it’s time for a new bed, shop around and try before you buy. Memory foam is comfortable but can be hot to sleep on. Comfortable pillows are equally important. If you’re a side sleeper, get an extra long (king-sized) pillow to place between your knees while sleeping. Note that sleeping on your back encourages sleep apnea.
2. Sleep cool (but not cold). To fall asleep, your body temperature must drop 1-2 degrees. Purging heat can help you fall asleep. Turn the thermostat down several degrees before bedtime. In the range of 65℉ to 72℉ is ideal for most people, but find what works for you. Use covers only as necessary, but have extra covers available in case you get too cool during the night.
3. Limit noise pollution. Any type of irregular noise, such as outside traffic, snoring bed-partners, or restless pets, can disrupt sleep. Beyond making your bedroom as quiet as possible, consider obtaining an electronic device that produces white noise to drown out surrounding sounds. It can be a device designed for that purpose, but your cell phone can work as well. During travel, silicone earplugs can be a good option for eliminating noise (but don’t use them on airplanes because of the abrupt pressure change).
4. Clean your sleeping environment. Dust, mold, clutter, and odors inhibit sleep. Wash your sheets and bed covers every couple of weeks. Reduce clutter where dust collects, and vacuum regularly. Place a HEPA air filter unit in the room where you sleep to clear the air (this is also a great option for white noise). Additionally, aromatherapy is another way to cultivate a favorable sleep environment. A drop or two of calming essential oils such as lavender, clary sage, or frankincense on your pillow can help soothe you into a restful sleep.
5. Isolate yourself as necessary. Be aware that your bed partner may be keeping you awake. Movement and snoring from a person or pet in the room may be contributing to insomnia. Consider sleeping in an isolated location until sleep is improved.
6. If possible, avoid alarm clocks. The best alarm clock is natural sunshine and normal circadian rhythm. If work obligations force you to rise before the sun, use a waking device that gently but persistently brings you awake.
7. Respect normal day and night cycles. If you work an odd shift and must sleep during the day, use darkening shades to completely darken the room where you sleep. Allow yourself a full eight hours of isolated sleep time to get the rest you need.
8. Rule out snoring If your partner reports that you snore excessively or sometimes wake in the middle of the night gasping, it may be worth an overnight stay in a sleep clinic to get a sleep test and rule out the possibility of sleep apnea.
9. Accept that some nights will be better than others. If you find yourself tossing and turning with your mind awake and alert, it means your brain has hit the panic button. A surge of adrenaline is readying your body for flight or conflict — the harder you fight it, the worse it’s going to get. Sometimes the only solution is getting out of bed to work out some of the tension, but if you can learn to short-circuit the stress response before it becomes established, your night will go smoother.
Relaxation exercises can help you break the cycle. Most online music vendors (Apple, Amazon, Spotify, Timer, Headspace, others) have audio files for breathing exercises and progressive relaxation. Try several. Practice them during the day, but have a cell phone or MP3 player by your bedside with earphones ready at night. Let it be your initial go-to solution when nighttime tension starts to rise.
When Nothing Else Works
Sometimes, when your sympathetic nervous system is especially keyed up from chronic stress or inflammation associated with relapse or herxheimer reactions, natural options may not be enough. On these occasions, the artificial sleep offered by prescription medications can be a relief.
Prescription sedative-hypnotic medications are the only solutions that are potent enough to completely override the extreme sympathetic overactivity blocking sleep. But there are risks associated with these medications, and you’ll want to be aware of them if you decide to use them.
Prescription medications can be habituating substances. Once your body becomes less responsive to a sleep drug, these medications may interrupt normal sleep, and they can come with a long list of side effects. Being habituated to a sleep medication can slow your recovery from chronic illness. Therefore, they will serve you best when you reserve them for occasional use — consider them your emergency solution. The recommendations for natural therapies and health practices above will help you reach your end goal — restoration of normal sleep patterns.
The Bottom Line
In the end, the three key components that lead to a good night’s sleep must include:
- Taking steps to calm the sympathetic nervous system during the day and early evening
- Building up sleep pressure during the day through physical activity
- Following a stable bedtime routine that promotes sleep every night.
These three steps combined with being proactive about your sleep habits is the best way to encourage a good night’s sleep. But try not to get too overwhelmed. If you can work on addressing these issues bit by bit, over time, you’ll be well on your way to restoring sleep and feeling more refreshed when you awake.
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