What herbs fight insomnia

Sleepless through the night

sleep disordersby Sabine Schellerer, Munich

Sleep is a guarantee for health and quality of life. It is all the more shocking that doctors and patients often underestimate the problem of insomnia. Those affected can definitely be helped. Often, even simple rules of conduct work wonders and make the nightly rest a blessing again.

According to a differentiated sleep disorder and insomnia study of more than 20,000 people, almost every second patient who consults his family doctor suffers from problems with sleep. This makes them the third most common reason for a visit to the doctor, right after physical illnesses and pain. With a prevalence of 32.2 percent, women are more likely to be affected than men (24.4 percent). It is frightening that a quarter of 16 to 19 year olds say they sleep poorly. For those over 80, the figure climbs to 41 percent (1).

No life without sleep

Anyone who struggles through the day like a dream after a wakeful night will experience firsthand that the organism can hardly function without a night's rest. Comparable to cigarette smoke or excessive alcohol consumption, insomnia can massively increase the risk of illness and cost the economy billions. A sleep deprivation of 24 hours damages the organism just as much as a per mille of alcohol. If you don't turn a blind eye at night, you run the risk of developing high blood pressure, coronary heart disease, gastrointestinal disorders or depression more quickly. According to various studies, people who sleep poorly are less successful at work than their well-rested colleagues. Because a good, deep sleep guarantees mental and physical performance; only those who are well rested can solve complex learning and practice tasks convincingly.

Studies previously documented that a lack of sleep can manifest itself with an increase in the body mass index. What is new is the finding that too little sleep seriously disrupts the balance of peptide hormones that control appetite and eating behavior. A recent study showed that after just two nights without sufficient rest, the leptin levels drop, while the levels of the appetite-stimulating hormone ghrelin rise. Incidentally, late risers should also be warned here: If you continuously fail to get out of bed for more than eight hours, your BMI is also damaged (2).

Scientists systematically dealt with sleep for the first time in the early twenties of the last century. Today, almost 200 special institutions in this country deal with it. However, what actually goes on in the body at night remains a mystery. Only fragments of involved neurophysiological processes are known so far. And the answer to the question of "why" should be worthy of the Nobel Prize, says Dr. med. Thomas Wetter from the Max Planck Institute for Psychiatry in Munich.

Most specialists agree that repair processes are in full swing during sleep and the body recovers (4). While a person is asleep, the heart usually beats more slowly, the blood pressure drops and the breath flattens. The body synthesizes most of the proteins during deep sleep. Glands stimulate the production of hormones. The concentration of somatotropin in the blood reaches peak values ​​at night, as does the prolactin level (17).

Researchers do not yet know in detail how sleep and the immune system are related. There are indications that a good night's sleep protects against tumors and strengthens the immune system against viruses, as the organism seems to release a particularly large number of immune-active substances, for example viral antibodies, after falling asleep (5). For a long time, experts have been discussing the extent to which sleep promotes learning and memory processes and helps the brain to process new information optimally. Procedural and declarative learning benefit equally from this (4).

Action in the brain

As a pair of brothers, sleep and death take shape in Greek mythology. Nevertheless, both have little in common. Electroencephalographic measurements of the brain wave show that, in contrast to death, the prototype of eternal standstill, sleep is a highly active process (4).

Five stages form a cycle that extends over 90 to 110 minutes. A healthy adult goes through four to six such cycles per night (Figure 1). So-called REM or paradoxical sleep remained a mystery for a long time. Muscle tension is almost completely lost here, and people are paralyzed. Only the eyeballs circling quickly and tirelessly under the closed lids; hence the name REM as an abbreviation for "rapid eye movements" (Figure 2). Breath and heart rate become irregular, and blood pressure rises. Since the blood flow in the brain swells and one dreams particularly vividly, this phase obviously serves to regenerate the CNS and the psyche. Researchers suspect that here the brain stores information that humans consider important into long-term memory, while discarding insignificant knowledge (6). Another thesis is that the brain matures here.

 

Illustration 1: The sleep profile of a healthy person shows the rhythmic change of sleep phases during the rest break.
(Please click on the picture to enlarge it.)

 

With the nucleus suprachiasmaticus, the control center of the sleep-wake period is located in the hypothalamus. It receives signals about the exposure of the retina via the collaterals of the visual pathway. It is also connected to the pineal gland, which produces the hormone melatonin. The hypothalamus as a higher-level brain area maintains contact with the area postrema, as well as with the raphe nuclei and the locus coeruleus in the brain stem. The control organ also communicates with the cerebral cortex via the lateral thalamus.

 

Figure 2: In the relaxed waking state, the EEG records regular alpha waves with a frequency of 10 Hz. As soon as sleep occurs, the alpha rhythm gives way to small, rapid and irregular oscillations. The person now goes through stage 1 or asleep, a transition phase between waking and sleeping. With stage 2, the actual beginning of sleep, the EEG waves get bigger and slower (theta waves). Here again and again spindle-shaped waves from 12 to 14 Hz superimpose the curve. This state dominates about half of all sleep. With the transition to phase 3 and 4, deep sleep begins. The amplitude of the brain waves continues to increase, but their frequency decreases and delta waves dominate the picture. In the following REM sleep, the EEG records theta waves again, which are similar to those of the sleep phase.
(Please click on the picture to enlarge it.)

 

Neurotransmitters relay the information between the involved areas in the brain. Experimental results suggest that serotonin is particularly involved. Cholinergic neurons in the bridge are believed to be particularly active during REM sleep. They inhibit spinal motor neurons via descending pathways and thereby relax the muscles. Noradrenergic pathways in the locus coeruleus appear to eventually terminate the REM phase. Researchers suspect that neurons of the nucleus tractus solitarii initiate orthodox sleep. Adenosine probably also helps you fall asleep and also maintains a state of rest. To explain the central fatigue effect, scientists postulate certain sleep substances that accumulate in the brain. These include the DSIP (delta sleep inducing peptide) (6).

Quality instead of just quantity

The rumor persists that only seven to eight hours of sleep guarantee a full quality of life. It is true that the individual needs differ greatly for genetic reasons. Napoleon felt fit after just four hours, while Albert Einstein slept for twelve hours.

In fact, the quality of your sleep is less important than the quantity. The body recovers especially during deep sleep. And no matter what time: The first four to five hours after nodding away you sleep deepest. An old wives' tale that only sleep before midnight promises true relaxation. However, chronobiology states that a person should ideally not go to bed early in the morning or during the day, as the change between light and dark controls his internal clock and thus sleep and wake rhythm.

There is hardly any cause for concern if you sleep away from time to time, for example before exams, while traveling or in times of family crises. Even a wakeful night can usually be handled by the body without any problems. However, if the disorders threaten to become chronic, action is required. Because after a while, endocrine processes are restructured in the brain. Then the evening cortisol levels rise, at the same time melatonin is released less. These changes can only be reversed with a lot of patience. (7).

88 reasons for Morpheus' escape

Diagnostic schemes such as the International Classification of Sleep Disorders (ICSD) and the DSM-IV define the disorder as clinically significant and in need of treatment if too little or unrestful sleep keeps the person awake at least three times a week and for at least one month at night, in an unacceptable ratio stands for a certain cause and always leads to daytime sleepiness with severe discomfort and limited social or professional performance.

Experts know 88 different reasons why the Sandman stays away. The 10th revision of the International Statistical Classification of Diseases (ICD-10) of the WHO classifies sleep problems according to syndrome-etiological aspects; the ICSD is mainly pathophysiological (17).

In terms of frequency, problems falling asleep and staying asleep, in technical jargon insomnias, are right at the top (Table 1). In most cases, persistent occupational overload, pressure to succeed, family problems or chronic stress do not allow the mind to calm down. Instead of triggering the sleep impulse, the hypothalamus constantly switches back and forth between sleeping and waking. Environmental factors such as noise or bright light often drive away sleep. Under certain circumstances, unusually low air pressure in the mountains, a lack of rituals and unsuitable mattresses can keep Morpheus away. Shift workers and members of the aircraft crew are often affected, because irregular living conditions bring chronobiology out of balance in the long term. Others are kept awake by the fear of not being able to sleep (10). In women, menstrual cramps, pregnancy or menopause can be behind it.

 

Table 1: Basic forms of sleep disorders (after 12)

Sleep disorderCharacteristics Insomnia main symptom: difficulty falling asleep or staying asleep or impaired sleep quality. Delayed induction of sleep; too little sleep or sleep disturbed by waking processes with consequent loss of daytime condition Hypersomnia Key symptom: excessive tendency to sleep during the day, sleep attacks or prolonged transition from sleep to wakefulness ("intoxicated sleep"); excessive daytime sleepiness with unwanted falling asleep, especially with monotonous activity; prolonged sleep period, more difficult to wake up Parasomnia mostly episodic events during sleep that are of disease value as such and not due to the disturbance of the sleep process, for example sleepwalking; Disturbances occur within sleep or at the sleep-wake threshold; The patient complains about the disorder, not about its influence on sleep disorders
Sleep-wake rhythm normal sleep, but the periodic alternation of waking and sleeping within the 24-hour day is not in sync with the desired and usually socially required sleep-wake pattern; Sleep periods shifted forwards or backwards in relation to the desired sleep time, irregular or frequently changing

 

Individual help needed

"Before each treatment, we have to try to get to the bottom of the problem, which is usually possible with a thorough anamnesis," stresses the psychiatrist Wetter. Almost all severe psychiatric illnesses are associated with sleep disorders. If they are treated adequately, the nocturnal problems usually also disappear. If the organism lacks oxygen due to asthma, bronchitis, febrile infections or cardiovascular diseases, sleep also suffers. Likewise, men who have benign prostatic hyperplasia constantly to the toilet at night hardly come to rest (9).

Many drugs also keep you awake (Table 2). Then the doctor, pharmacist and patient must jointly check whether it is possible to discontinue the medication or to change the rhythm or dose.

 

Table 2: Drug groups that can disrupt sleep (8, 11, 12)

Drug groupExamples Antibiotics Gyrase inhibitors Anticholinergics Antidepressants MAO inhibitors, SSRIs, tricyclics Antihypertensives ACE inhibitors, beta blockers, clonidine, calcium antagonists Bronchodilators Theophylline Diuretics due to nocturia (if taken in the evening) Dopaminergics, drugs, thyroid gland, and nicotine drugs, coconut, contraxic drugs, thyroid hormones, cannabis, anti-glucocortic drugs, coccortic hormones, illegal thyroid, thyroid, and thyroid hormones, coconut hormones, coconut hormones, coconut hormones, cannabis, antihypertensive tricyclics , Heroin, ecstasy neuroleptics due to dyskinesia, parkinsonoid sedatives and hypnotics antihistamines, benzodiazepines (for high dose dependency and withdrawal), hypnotics with a short duration of action (rebound phenomenon) stimulants appetite suppressants sympathomimetics circulatory drugs cytostatics

 

Sometimes a sleep log helps to characterize the condition more precisely. “Many patients judge themselves completely wrong and suspect problems where there are none. Documenting habits and processes is useful here, ”says Wetter. In severe cases, an exact physical and psychological examination in the sleep laboratory puts the doctor on the right track.

Each therapy should be individually tailored to the person concerned. "Often a lot is gained if the patients consistently pay attention to correct sleep hygiene," knows the qualified psychologist Stephany Fulda from the Max Planck Institute for Psychiatry in Munich. Sleeping pills help in crisis situations, to calm you down before an operation, in acute emotional distress or in unusual, short-term stressful situations. They do not fight the cause of the problem, but - taken half an hour before going to bed - they give you relaxation. They must never become a permanent solution.

Plant power creates sleep

In the case of nervous insomnia, it makes sense to use herbal supplements, which clinical studies have also confirmed. Older, multimorbid patients in particular benefit from the low-side effects sleep aids.

If medication is behind restlessness at night, the herbal remedies can also help, especially those with a broad spectrum of action - such as the passion flower, which has a simultaneous sedation and spasmolytic effect on asthmatics who need corticosteroids or theophylline. Lemon balm leaves are good for children who suffer from constant stomach ache from falling asleep. Because carminative, sedative and spasmolytic effects all have an impact here. Herbs are less effective in combating sleep disorders.

Lavender flowers, lemon balm leaves, valerian roots and hop cones increase the readiness for sleep and normalize the physiological process without disturbing REM or deep sleep. Even with an overdose, there are no narcotic effects. The individual night sedatives complement each other in their effect and can be combined sensibly. Important: Phytopharmaceuticals do not work immediately, but usually only after two to four weeks of consistent ingestion in a sufficiently high dose. Negative reports about valerian root extract were based on insufficiently high doses, as an ethanolic aqueous extract only has a sedative effect at 600 to 1000 mg per day. Furthermore, not all valerian is created equal. Only the European representative Valeriana officinalis received a positive monograph as a night sedative. The lower content of valepotriates makes Mexican or Indian exotic species into daily sedatives.

Hop cones promise sleep from a dosage of 40 to 90 mg dry extract (1: 5-7). In combination with valerian, 10 to 65 mg is sufficient. In the case of lemon balm leaves, the fresh plant juice in particular provides the single dose of 80 to 100 mg dry extract recommended by Commission E. The Roman legionaries already valued the power of lavender and carried the blue flowering herb with them on crusades. The oil unfolds its sedating effect through the skin and respiratory tract (8).

Beware of antihistamines

When histamine excites central H1 receptors, sleep is almost impossible. As a side effect, older, centrally active H1 antihistamines block these binding sites - that is why the derivatives diphenhydramine and doxylamine are on the market as pharmacy-only sleep aids. However, many experts reject uncritical self-medication and the active ingredients are not mentioned in relevant guidelines. Above all, habituation effects and the risk of hangover are rated as negative; the healthy sleep architecture, especially dream sleep, suffers from antihistamines. Their potential for interaction is also significant. Antidepressants, for example, aggravate antihistaminergic side effects such as dry mouth or visual disturbances.Strong painkillers or Parkinson’s drugs and anti-epileptic drugs, but also alcohol, increase their effects.

Under no circumstances should the funds be swallowed for more than three days in a row and for a maximum of three weeks. The single dose must not exceed 50 mg.

Sleepmaker with prescription

When the chemist Leo Sternbach tried to clear out his overcrowded laboratory table in 1957, a conspicuous crystal suspension caught his eye. Felix Randall, an accomplished pharmacologist, immediately saw the value of this chance product.

With chlordiazepoxide it was believed that they had finally found the ideal sleep aid. Because compared to the barbiturates, the substance performed far better in terms of therapeutic breadth and addiction development. Researchers set out to synthesize countless derivatives and refine the molecular structure. In the USA in particular, there was a stormy run on the supposed miracle pills. Phenobarbital and Co., until now the market leader in the sleep aid sector, were largely forgotten.

But the disillusionment followed on the foot, because the supposedly ideal sleeping pills also showed their pitfalls. If it is taken continuously for more than four weeks, tolerance and physical dependence can develop. Psychological addictions are also known. According to surveys by the German Central Office for Addiction Issues, more than a million people in Germany are dependent on benzodiazepines. The box office hits are at the forefront of the most abused substances.

Another problem is that some derivatives, especially flurazepam or nitrazepam, are only metabolized very slowly and continue to work well into the next day. As a result, patients feel drowsy and suffer from disorientation, reaction and concentration problems, or confusion. Older people in particular are now at greater risk of falling. And those who actively participate in road traffic are putting themselves and others in danger. Especially with short-acting derivatives such as triazolam or brotizolam, the brain stores memory contents much worse, which in the worst case can lead to amnesia.

Benzodiazepines increase the inhibitory function of GABAergic neurons by increasing the affinity of the neurotransmitter to the receptor. The pharmacological spectrum is largely the same for all substances. They have anxiolytic, anticonvulsant and muscle relaxing effects. Depending on the dose, its sedating component changes into a hypnotic one. The remedies have little effect on REM sleep, but lengthen sleep stages 2 and 3 and shorten stage 4.

In order to avoid hang-over effects, short or medium-term preparations with the ingredients brotizolam, lormetazepam or temazepam are recommended. Triazolam is metabolized particularly quickly and combats problems falling asleep, less problems staying asleep. Since the full effect is already achieved after ten minutes, it should be swallowed immediately before going to bed. Grapefruit juice increases the effectiveness of triazolam, which in the worst case scenario can lead to tiredness and drowsiness the next day (14).

Beware of benzodiazepine medication for seniors: their metabolism works more slowly, and overdosing often leads to paradoxical effects. Intermittent therapy helps prevent addiction. When dealing with hypnotics, experts refer to the 5K rule, which states: clear indication, smallest possible dose, short duration, no abrupt discontinuation, observe contraindications (16).

Although not chemically related, zolpidem, zopiclone, and zaleplon have the same mechanism of action as the benzodiazepines. They too dock on a subunit of the GABA-A receptor chloride channel, but at a different binding site. As a result of the low affinity for the receptors located in the spinal cord, muscle-relaxing and anticonvulsant properties are hardly pronounced. Nevertheless, there is also the risk of unsteady gait and falls, especially with seniors. Initial studies suggested that their addiction potential is significantly lower. However, there is still a lack of meaningful long-term studies. According to experts, benzodiazepine addicts can hardly be switched to zolpidem and the like without risk. One advantage of the second generation hypnotics: They interfere less strongly with the physiological sleep pattern than their predecessors.

The potential dependency stands in the way of long-term treatment with hypnotics - for the psychiatrist Wetter, a clear argument in favor of antidepressants with antihistaminergic components. Doctors also like to switch to trimipramine, doxepin or mirtazapine for seniors or people at risk of addiction. In addition, the sedating psychotropic drugs hardly change the physiological sleep pattern. Only sometimes does deep sleep intensify, which therapists prefer to do with depressed patients. In lower doses than for the treatment of depression, the agents often guarantee those affected a restful sleep for years. Why many general practitioners refrain from sleep-inducing antidepressants, Wetter explains with the diverse spectrum of interaction. Neuroleptics, on the other hand, no longer play a major role in sleep medicine, so they are »out«, says the psychiatrist.

Exotics that promise sleep

Melatonin (15), a hormone that is produced in the epiphysis from serotonin via two enzymatic steps, controls the sleep-wake cycle and makes you tired. If only a small amount of light falls on the retina, the gland increases production. And the blood level also rises during the winter months.

It has been possible to buy the messenger substance in the USA as a synthetic drug without a prescription since the 1990s. Modern formulations keep the concentration in the blood for six hours at a level that promises sleep. Because many media advertise melatonin as a miracle drug that combats insomnia and also promises youthfulness and well-being, corresponding products are selling well.

"Melatonin is a chronobiotic that influences the circadian rhythm," says Stephany Fulda. Only if there is a demonstrable deficit in the body may the intake be beneficial, for example for blind people who lack external timers because their retina receives little or no light. According to positive study results (18), approval procedures for this patient group are ongoing. For years, clinical studies have been investigating the neurohormone with good success in jet lag.

Seniors, whose circadian rhythms are sometimes tremendously out of balance, could also benefit from the chronobiotic. However, their insomnia is usually very complex and a lack of melatonin is just one factor among many. In addition, there is a lack of meaningful clinical studies on older people.

Melatonin is not permitted in Germany; possible side effects and long-term effects have not yet been adequately investigated. It can only be used in clinical studies.

L-tryptophan, an essential amino acid that the organism enzymatically converts into serotonin in appropriate nerve cells through hydroxylation and decarboxylation, follows a causal therapy principle. Because the neurotransmitter cannot cross the blood-brain barrier, oral administration would not be effective. This is where its preliminary stage comes in: L-tryptophan reaches the thinking organ undamaged, is supposed to compensate for a lowered serotonin concentration and bring the natural sleep rhythm back into balance. In practice, the active ingredient is rarely used, and the data are poor.

Underestimated suffering

Around every fifth German citizen complains of problems falling asleep and staying asleep - a real common ailment. In most cases, there are ways and means to prevent years of suffering, provided that a specialist comes in who takes the patient seriously. Synthetic sleeping pills are only suitable in crisis situations; Phytopharmaceuticals provide gentle help. A change in sleeping habits can often bring improvement (box).

 

Sleep hygiene tipsSleep is promoted through bedtime rituals (regular sleep and wake up times), relaxation techniques (autogenic training, yoga), light physical activity (evening walk), alternating showers and regular endurance sports.

One should avoid Overstimulation (noise, light, exciting activities), caffeine and alcohol in large quantities, nicotine, late and / or heavy meals (risk of heartburn), accumulated stress, grief, fears and small naps during the day.

One should pay attention a pleasant sleeping atmosphere (pay attention to the quality of the mattress); the ideal room temperature is 18 degrees Celsius; fresh air; only go to bed to sleep (not working, watching TV, reading); do not lie awake in bed for hours, rather get up in between and read outside of bed; only go back to bed when you feel tired; Get up at the same time every day and get used to a regular daily rhythm. After (12)

  

Incidentally, Professor Dr. Göran Hajak, Medical Director of the Sleep Medicine Center at the University of Regensburg, clearly refrained from trying to cure sleep disorders on your own. The danger of procrastinating supposedly harmless sleep problems is too great. “The patients belong in the hands of a doctor. Only he can get to the bottom of the suffering and thus prevent the disturbances from taking on a life of their own. «Sensitive and responsible advice in the pharmacy can point the patient in the right direction and accompany him in the process.

 

literature

  1. Wittchen, H.-U., et al., NISAS-2000 the Nationalwide Insomnia Screening and Awareness Study. Neurology 20 (2001) 4-16.
  2. Spiegel, K., et al., Brief communication: Sleep curtailment in healthy young men is associated with decreased leptin levels, elevated ghrelin levels, and increased hunger and appetite. Ann. Internal Med. 11, Vol. 141 (2004) 846-850.
  3. Taheri, S., et al., Short sleep duration is associated with reduced leptin, elevated ghrelin, and increased body mass index. PloS Medicine 3, Vol. 1 (2004) e62.
  4. Borbely, A., Sleep. Fischer Taschenbuch Verlag, Frankfurt a. Main 2004.
  5. Schuld, A., et al., Experimental studies on the interaction between sleep and the immune system in humans. Psychother. Psychosom. Med. Psychol. 55 (2005) 29-35.
  6. Mutschler, E., et al., Drug Effects. 8th ed., Wiss. Publishing company. Stuttgart 2001.
  7. Leinmüller, R., Insomnia: Medicinal palette enables individual therapy. German Doctor bl. 97, No. 48 (2000).
  8. Schilcher, H., Kammerer S., Guide to Phytotherapy. 2nd edition, Urban & Fischer Munich 2003.
  9. Holst, S., Meiser, U., The great TRIAS advisor for healthy sleep. Trias Verlag 2004.
  10. AWMF guidelines on sleep medicine: non-restful sleep.
  11. Guidelines of the German Society for Neurology: Non-restful sleep.
  12. Wahle, K., Faust, V., BDA-Manual sleep. Ifap-GmbH, service institute for doctors and pharmacists.
  13. Bavarian Chamber of Pharmacists, tips for a healthy sleep. Pharmaceutical Care Quality Circle.
  14. Lilja, J.J., et al., Effect of grapefruit juice dose on grapefruit juice-triazolam interaction: repeated consumption prolongs triazolam half-life. Eur. J. Clin. Pharmacol. 56, No. 5 (2000) 411-415.
  15. Arzneitelegramm 12 (1995) 114.
  16. Klotz, U., Laux, G., Tranquillants. 2nd ed., Wiss. Publishing company. Stuttgart 1996.
  17. Saletu, B., Saletu-Zyhlarz, G. M., Everything you always wanted to know about sleep. Überreuter Vienna 2001.
  18. Fischer, S., et al., Melatonin acutely improves the neuroendocrine architecture of sleep in blind individuals. J. Clin. Endocrine. Metabolism 11, Vol. 88 (2003) 5315-5320.

 

The author

Sabine Schellerer studied pharmacy in Munich and received her license to practice medicine in 1993. From 1994 to 2000 she worked at the Institute for Forensic Medicine at the University of Munich on her doctorate and during this time also worked in public pharmacies. She then completed an apprenticeship as a trade magazine editor as well as internships in several publishing houses. Since mid-2002, Dr. Schellerer works as a freelance science and medical journalist.

 

Author's address:
Dr. Sabine Schellerer
Wichertstrasse 13
80993 Munich
[email protected]

© 2005 GOVI-Verlag
Email: [email protected]