Eliminating the Top Causes of Insomnia: Neurotransmitter Deficiency and Cortisol Excess
A guest post by Julia Ross on uncovering the top causes of insomnia and how to best eliminate them.
With over 25 years of experience as the director of a holistic clinic in the San Francisco Bay Area, our clinic has provided nutritional therapy to over two thousand insomniacs. The careful identification and targeted recommendations of the underlying causes of each sleep disorder have led to successful outcomes in almost every case. At least half of our sleepless clients have responded quickly and well to neurotransmitter precursors such as GABA, tryptophan, and/or melatonin. Others have required very specific cortisol-lowering regimens instead or in addition. These latter cases have tended to involve more severe sleep disturbances and, often, the use of highly addictive benzodiazepines, the only class of pharmaceutical in current use capable of temporarily suppressing cortisol levels.
INITIAL INTERVIEWS WITH INSOMNIACS
A detailed sleep function assessment has been crucial for determining the course of successful therapy:
- How long have you had a sleep problem?
- Did it begin during or after a particularly stressful time?
- Does insomnia run in your family?
- What time do you get to sleep?
- How long does it take to fall asleep? How long do you sleep?
- How often do you wake up in the night? For how long?
- Do you need to take benzodiazepines such as Xanax, Ativan, or Klonopin to sleep? Or marijuana? Or alcohol? Or carbs?
- Do you have many of the symptoms of any of the following three types of insomnia?
TYPE ONE INSOMNIA: SEROTONIN/MELATONIN DEFICIENCY
This is the most common cause of insomnia in our experience: When levels of the extraordinary antidepressant neurotransmitter, serotonin, are subnormal, there is typically an inadequate surplus to use for conversion to melatonin. What results is a difficulty falling asleep (night owl syndrome) more commonly than one of staying asleep (though either or both may be present.) Either way, worries and obsessive thoughts make wakefulness unpleasant. This syndrome is often genetic and longstanding (though the severity may have increased over time.)
The following is a list of the common symptoms of serotonin deficiency, which helps us rule this syndrome in or out as a cause of the particular insomnia being endured. We ask that it be filled out using a severity scale from 1 to 10.
- night-owl, hard to get to sleep
- disturbed sleep, premature awakening
- negativity, depression
- worry, anxiety
- low self-esteem
- obsessive thoughts or behaviors
- perfectionism, controlling behavior
- winter blues
- irritability, rage (e.g. PMS)
- dislike hot weather
- panic attacks; phobias (fear of heights, small spaces, snakes, etc)
- fibromyalgia, TMJ, migraine
- afternoon or evening cravings for carbs, alcohol, or pot
Note: The frequent use of benzos is not part of this syndrome.
Regarding Serotonin Testing: Blood platelet testing for serotonin levels is superior to any but cerebrospinal fluid testing and almost as hard to find. Blood plasma testing gives a rougher idea of actual levels. Research and practice have convinced us that urinary neurotransmitter testing is very unreliable. (See my article on this subject originally published in the TL 10/06 and posted on my website. We like salivary melatonin testing.
RECOMMENDATIONS FOR TYPE ONE INSOMNIA
Tryptophan (500 – 2000 mg for adults– less with children), taken when insomnia occurs, e.g., at bedtime and/or in the night, is the first recommendation of choice. 5HTP raises cortisol (should hypercortisolism also be an issue) so we avoid it in serious insomnia cases (otherwise nightmares or other sleep deterioration can result.) If tryptophan does not do the whole job, we add melatonin (.5 – 5 mg) as an immediate-release supplement for bedtime-only insomnia, or in a delayed-release form for later-in-the-night awakenings.
Regarding dosing: We start with the lowest dose and have our clients go up as needed. Children under 14 start with a small amount from an opened capsule, mixed with mashed fruit or any other palatable protein-free food. The younger and more sensitive the child, the less provided.
TYPE TWO INSOMNIA: GABA DEFICIENCY
Gamma aminobutyric acid is the brain’s primary inhibitory (i.e., calming) neurotransmitter. It neutralizes adrenaline as a primary function. A GABA deficiency can accompany a serotonin/melatonin deficiency, or cause sleep problems on its own. Here, muscle tension and other symptoms of overstress interfere with sleep. The following is a list of common symptoms of GABA deficiency which, again, helps us to determine if this syndrome is a significant factor in a particular case of insomnia: overstressed, burned out, unable to relax/loosen up, stiff or tense muscles, often feel overwhelmed, may experience panic attacks, when resorting to sleep meds respond best to the benzodiazepines.
Regarding GABA Testing: We are not satisfied with any lab testing for levels of this neurotransmitter. (GABA is not found in the platelets.)
RECOMMENDATIONS FOR TYPE TWO INSOMNIA:
100-500 mg of GABA taken whenever sleep is a problem can be very helpful along with, or instead of, tryptophan/melatonin.
Note: Neuroscience and Senesco make the signature error of while recommending that levels of the inhibitory neurotransmitter GABA be enhanced, not recommending GABA supplementation itself. GABA is wildly effective (at 100-500 mg, at bedtime and/or later in the night on awakening) for all over-stressed states, including many cases of insomnia. We do avoid GABA 750 mg, as a reverse syndrome (e.g., anxiety) may develop at such high doses. In the few non-responders to GABA, l-theanine often provides a very similar calming effect.
TYPE THREE INSOMNIA: HIGH CORTISOL
Excessive stress always raises our levels of the stress-coping giant, cortisol, the chief of our stress-response team (which also includes adrenaline and endorphin.) Chronic stress can lead to a permanent hyper-cortisol state—even long after the precipitating events have resolved. When this disturbance occurs at night, when cortisol levels should be at their lowest, the quality of insomnia is typically an alert “ready to get to work” one or an agitated and hyper-vigilant, or even a startled or shocked sensations on sudden nocturnal awakening.
Because chronically elevated cortisol suppresses serotonin and exhausts GABA, the worried Type One and tense Type Two Insomnia conditions are a regular, but minor, feature here.
LOWERING CORTISOL LEVELS
We start by providing rich, basic adrenal support using high dose multi-vitamins, multi-minerals, and extra vitamin C to support a blood-sugar stabilizing diet of at least 3 meals, each including 20-25 grams of protein, adequate fat, and no sugar or other refined carbs. We typically suggest 1000-1500 mg of glutamine between meals to support blood sugar stability. If compliance is a problem, we refer clients to the questionnaire from my book The Diet Cure, to identify whether persistent carbohydrate cravings may be due to neurotransmitter deficits, chronic under- eating/dieting, food allergy, yeast overgrowth, or sex hormone dysregulation.
Providing nutrient supplements that specifically lower cortisol: Perhaps 15% of cases of chronically elevated nocturnal cortisol respond well to GABA and/or tryptophan or melatonin. The rest require the nutrients I’ll mention next.
Cortisol-lowering Herbs: Holy Basil can be helpful, as can reishi and magnolia bark. Acupuncture and/or Chinese herbs for kidney/adrenal treatment should always be considered, especially when cortisol is elevated during the day as well as at night.
Avoid supplementation with stimulating, cortisol-elevating nutrients: For example, insomnia caused by high cortisol is not eliminated, but, rather, exacerbated by the use of the stimulating amino acid, l-tyrosine (l-tyrosine converts to noradrenaline and adrenaline.) If indicated by the noradrenaline deficiency symptoms of fatigue or poor concentration, we might recommend tyrosine in the AM only. Typically we forgo such treatment until after cortisol levels are lowered, and often find that the resulting improved sleep alone restores energy and focus.
The “adaptogenic” herbal mixtures recommended by many practitioners typically contain ashwagandha and licorice, which elevate cortisol. Ashwagandha has proven to be energizing (and licorice certainly is.) We have found these herbs, even when combined with more calming herbs, to be too stimulating for many of our already hyper and sleepless high-cortisol clients. (We like them for clients who need help raising low cortisol levels, but we prefer Isocort.)
Other Cortisol-Normalizing Considerations: Stress reduction/management needs, the use of caffeine, alcohol, and other cortisol-elevating drugs, as well as excessive dieting or exercise (which also elevates cortisol, may need to be evaluated and addressed.
Where benzodiazepines have been used as regular sleep aids and addiction has resulted, a gradual taper, supported by all of the above nutrients, as needed, guided by the Ashton Manual may be required. IVs emphasizing vitamin C (15-25 grams) and taurine are helpful on taper days to reduce or eliminate withdrawal symptoms. (IV-administered GABA sometimes has adverse effects, but taurine strongly and benignly supports GABA function in the brain.)
With the proper use of the right testing and nutritional tools, stubborn insomnia caused by neurotransmitter deficiency and/or chronically elevated cortisol can be cured very quickly as our clinic has seen in literally thousands of cases.
This post originally appeared in the Spring 2011 edition of The Nutritional Therapist.