Insomnia, Substance Use, & Anxiety: Looking to the Therapeutic Order to Restore Balance
Student Scholarship – 3rd Place Case Study
Jennifer Brusewitz, ND
As naturopathic physicians, we understand that quality sleep is foundational to our patients’ well-being. Many patients suffer from comorbid conditions that interfere with their ability to get the proper amount of restorative sleep. Addressing disturbed sleep is critical to the treatment of any health condition when following the Therapeutic Order.
Insomnia & Substance Use
Insomnia can be categorized as acute or chronic. Acute insomnia lasts less than 3 months and is often situational due to increased stress, whereas chronic insomnia must occur at least 3 times a week for 3 months or longer. Chronic insomnia can last over 1 year for 74% of patients and over 3 years for 46% of patients.1 Insomnia is highly prevalent, affecting 10-15% of the general population, and is often comorbid with psychiatric illnesses, including posttraumatic stress disorder (PTSD) and substance-use disorders.2
The relationship between insomnia and mental health is complex, with causation vs correlation unclear. However, approximately half of patients with chronic insomnia have a comorbid psychiatric disorder, and, conversely, the majority of patients with a psychiatric disorder report insomnia that often preceded the development of their mental health issues.3 Therefore, insomnia appears to be a significant risk factor for the development of psychiatric conditions, especially major depression.4 Similarly, while 70-90% of patients with PTSD have either sleep-onset or sleep-maintenance insomnia, chronic sleep loss is alternately a risk factor for developing PTSD, depression, and anxiety if exposed to traumatic events.5
Insomnia is also often comorbid with substance-use disorders (SUD), defined as the overuse or inability to control one’s use of substances such as drugs or alcohol. Insomnia and SUD appear interconnected, with myriad data confirming the association. Longitudinal studies have found that insomnia in adolescence is associated with early use and abuse of alcohol, cannabis, or illicit drugs, as well as more severe addiction.6 Insomnia also predates alcohol dependency in the majority of patients with alcohol-use disorder and is a risk factor for relapse.7 As rates of anxiety are increasing, even among children and teens,8 more and more patients are turning to substance use, including alcohol and marijuana, in order to cope.9,10 Some recent statistics report that 22% of young adult patients use marijuana,11 35% of adults engage in binge drinking,12 and 6.5% of adults reporting alcohol-use disorder.13 Addressing insomnia during recovery from SUD is crucial, as insomnia has been related to higher rates of relapse.7
The physiologic impact of SUD on sleep is variable, depending on the drug of misuse, although chronic substance use of any kind often results in sleep-initiation insomnia, reduced total sleep time, increased nighttime awakenings, decreased slow-wave sleep, and decreased REM sleep.14 These symptoms may persist past the acute withdrawal period. In one recent study, 33% of patients reported insomnia for up to 2 years after discontinuing the use of marijuana.14 Methamphetamine use can also lead to chronic insomnia, as it is a potent neurotoxin that disrupts circadian rhythms and causes long-term structural changes to the brain.15
In this case report, we will discuss a naturopathic approach to a combination of insomnia, psychiatric illness, and SUD.
Presenting Concerns & Clinical Findings
A 25-year-old female presented to our clinic for management of chronic insomnia. She reported anxiety and PTSD with nightmares that had been worsening in frequency and intensity during the previous month, resulting in difficulty in both initiating and maintaining sleep. She also reported fear around falling asleep.
The patient had a 4-year history of heavy marijuana use, a 1-year history of cocaine use, and a 3-week history of intravenous methamphetamine use. She had abstained from all drug use for 4 months prior to her first office visit for naturopathic services. Her past medical history was significant for anxiety, depression, ADHD, PTSD, and a suicide attempt at age 13. Review of systems was positive for headaches and diarrhea, but was otherwise unremarkable. Her family history included substance-use disorders, depression, anxiety, and bipolar disorder. A screening physical exam was unremarkable. We administered a GAD-7 (a commonly used screening questionnaire to assess anxiety), which was scored at 14, indicating moderate anxiety.16
Our differential diagnosis for chronic insomnia included volitional sleep restriction, environmental disruptions to sleep, sleep apnea, restless leg syndrome, and physical health conditions such as GERD and dementia, which can interfere with sleep. Insomnia is most frequently a clinical diagnosis, and there was low suspicion of any primary sleep disorders, so no further work-up was pursued at this time.
We approached this case from the base of the naturopathic Therapeutic Order, using sleep hygiene, herbs, and nutrients to support our patient’s sleep, thus strengthening the foundations of her health. Our goal was to offer palliative and restorative treatments to improve her sleep quality, decrease nightmares, and reduce anxiety around sleep, followed by addressing lifestyle components such as sleep hygiene.
Encapsulated lavender essential oil was prescribed at a dosage of 80 mg twice daily, in the morning and evening. Encapsulated lavender essential oil has been shown to be as effective as paroxetine for the treatment of generalized anxiety disorder,17 and has also been shown to improve sleep quality in patients with anxiety18 and PTSD.19 Lavender has traditionally been thought to act on GABA1 receptors, similarly to benzodiazepines. However, recent research has shown it to cause inhibition of voltage-dependent calcium channels in primary hippocampal neurons, similar to the action of pregabalin, a GABA analogue used to treat nerve pain.18 Lavender also reduces the binding capacity of serotonin receptors in the hippocampus.18 While serotonin promotes wakefulness, serotonin antagonists such as lavender can be sedating.20
Additionally, L-theanine capsules were recommended before bed, at a dosage of 100-200 mg. L-theanine, an amino acid found in green tea, is used in the treatment of anxiety and insomnia.20,21 It acts by increasing GABA, an inhibitory neurotransmitter, and antagonizing glutamate, an excitatory neurotransmitter; these combined properties result in anxiolytic effects.20,21 L-theanine has been shown to improve sleep onset and increase time spent in REM sleep, as well as increase sleep maintenance in patients with ADHD.21,22
The patient returned to clinic 1 week after her initial appointment. She was compliant with our treatment plan, though she denied improvement in her sleep onset or sleep maintenance. However, she did not experience any nightmares since the last office visit, which eased her nighttime anxiety. The patient was encouraged to continue taking the lavender essential oil capsules and L-theanine for at least a 1-month trial.
Sleep hygiene recommendations were also given. Improving sleep hygiene has been shown to improve insomnia symptoms, especially when insomnia is mild or when sleep hygiene serves as an adjunctive therapy.23 The patient was educated about the negative effects of screen exposure on sleep. Increased exposure to monitors and device screens, especially before bed or when waking in the night, has been associated with increased rates of insomnia, increased sleep latency, and decreased total sleep time.24 The blue light emitted from screens causes physiologic activation, resulting in decreased natural melatonin production, changes in hormone production, and dysregulation of the hypothalamic-pituitary-adrenal axis.24 The patient was counseled to avoid all screens for 1 hour before bed and upon waking during the night. The importance of keeping her room cool and dark, dimming lights 1 hour before bed, and keeping a consistent bedtime schedule, were also discussed.
One week later, the patient had implemented the sleep hygiene suggestions and reported resolution of sleep-onset insomnia and a 50% reduction in sleep-maintenance insomnia. She continued to deny any adverse effects from the supplementation.
This patient was simultaneously accessing counseling services. Nonpharmacologic treatments for insomnia, such as cognitive behavioral therapy for insomnia (CBT-I) are considered first-line approaches for patients with SUD. CBT-I alone or in combination with pharmacotherapy has been shown to be more effective than pharmacologic monotherapy for chronic insomnia, especially for patients with maladaptive attitudes and behaviors surrounding sleep.25 CBT-I has also been shown to improve sleep parameters and psychosocial functioning in veterans with PTSD over the course of 8 weekly sessions.26
The patient wished to avoid pharmaceutical interventions, as she was hoping to use a natural approach without side effects. Pharmaceutical medications used for insomnia include sedating antidepressants, anticonvulsants such as gabapentin, melatonin agonists such as ramelteon, as well as antipsychotics for patients with comorbid SUD.25 When nightmares due to PTSD are contributing to insomnia, prazosin may be prescribed. Prazosin is an alpha-1 adrenergic antagonist that, when used in low doses, crosses the blood-brain barrier to decrease sympathetic nervous system activity in the brain that is responsible for nightmares.27 Many of these pharmaceutical interventions have side effects that include drowsiness, dizziness, and fatigue.
Our decision to provide encapsulated lavender essential oil and L-theanine for symptom relief before suggesting a sleep hygiene protocol was based on our experience that the latter can be difficult for some patients to implement. While not immediately effective, the simple protocol inhibited the glutamatergic and serotonergic pathways that may have been contributing to increased wakefulness and exacerbating the recurring nightmares that were interfering with sleep. With continued use of these agents, along with the addition of sleep hygiene recommendations at follow-up visits, the patient experienced significant restoration of recuperative sleep.
This case study offers examples of safe and effective, nonpharmacological treatment options when anxiety, depression, and SUD are present comorbidly with insomnia. The combination of sleep hygiene education and herbal and nutrient support represents a powerful natural approach, even when insomnia is complicated by challenging life circumstances.
- Morin CM, Bélanger L, LeBlanc M, et al. The natural history of insomnia: a population-based 3-year longitudinal study. Arch Intern Med. 2009;169(5):447-453.
- Shochat T, Umphress J, Israel AG, Ancoli-Israel S. Insomnia in primary care patients. Sleep. 1999;22 Suppl 2:S359-S365.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: American Psychiatric Association; 2013.
- Alvaro PK, Roberts RM, Harris JK. A Systematic Review Assessing Bidirectionality between Sleep Disturbances, Anxiety, and Depression. Sleep. 2013;36(7):1059-1068.
- Gehrman P, Seelig AD, Jacobson IG, et al. Predeployment Sleep Duration and Insomnia Symptoms as Risk Factors for New-Onset Mental Health Disorders Following Military Deployment. Sleep. 2013;36(7):1009-1018.
- Wong MM, Robertson GC, Dyson RB. Prospective relationship between poor sleep and substance-related problems in a national sample of adolescents. Alcohol Clin Exp Res. 2015;39(2):355-362.
- Weissman MM, Greenwald S, Niño-Murcia G, Dement WC. The morbidity of insomnia uncomplicated by psychiatric disorders. Gen Hosp Psychiatry. 1997;19(4):245-250.
- Centers for Disease Control and Prevention. Anxiety and depression in children: Get the facts. Updated April 15, 2019. CDC Web site. https://www.cdc.gov/childrensmentalhealth/features/anxiety-depression-children.html. Accessed December 9, 2019.
- Schuckit MA. Remarkable Increases in Alcohol Use Disorders. JAMA Psychiatry. 2017;74(9):869-870.
- NIH National Institute on Drug Abuse. Drug and Alcohol Use in College Age Adults in 2017. Updated 2017. NIH Web site. https://www.drugabuse.gov/related-topics/trends-statistics/infographics/drug-alcohol-use-in-college-age-adults-in-2017. Accessed December 9, 2019.
- NIH National Institute on Drug Abuse. Marijuana. Updated 2018. NIH Web site. https://www.drugabuse.gov/drugs-abuse/marijuana. Accessed December 9, 2019.
- Krieger H, Young CM, Anthenien AM, Neighbors C. The Epidemiology of Binge Drinking Among College-Age Individuals in the United States. Alcohol Res. 2018; 39(1):23-30.
- NIH National Institute on Alcohol Abuse and Alcoholism. Alcohol Facts and Statistics. Updated December 2019. NIH Web site. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-facts-and-statistics. Accessed December 9, 2019.
- Hasler BP, Smith LP, Cousins JC, Bootzin RR. Circadian Rhythms, sleep, and substance abuse. Sleep Med Rev. 2012;16(1):67-81.
- Ardani AR, Saghebi SA, Nahidi M, Zeynalian F. Does abstinence resolve poor sleep quality in former methamphetamine dependents? Sleep Sci. 2016;9(3):255-260.
- Williams N. The GAD-7 questionnaire. Occupational Medicine. 2014;64(3):224.
- Kasper S, Gastpar M, Müller WE, et al. Lavender oil preparation Silexan is effective in generalized anxiety disorder – a randomized, double-blind comparison to placebo and paroxetine. Int J Neuropsychopharmacol. 2014;17(6):859-869.
- Kasper S, Anghelescu I, Dienel A. Efficacy of orally administered Silexan in patients with anxiety-related restlessness and disturbed sleep – A randomized, placebo-controlled trial. Eur Neuropscyhopharmacol. 2015;25(11):1960-1967.
- Uehleke B, Schaper S, Dienel A, et al. Phase II trial on the effects of Silexan in patients with neurasthenia, post-traumatic stress disorder or somatization disorder. Phytomedicine. 2012;19(8-9):665-671.
- Watson CJ, Baghdoyan HA, Lydic R. Neuropharmacology of Sleep and Wakefulness. Sleep Med Clin. 2010;5(4):513-528.
- Kim S, Jo K, Hong KB, et al. GABA and l-theanine mixture decreases sleep latency and improves NREM sleep. Pharm Biol. 2019;57(1):65-73.
- Lyon MR, Kapoor MP, Juneja LR. The effects of L-theanine (Suntheanine®) on objective sleep quality in boys with attention deficit hyperactivity disorder (ADHD): a randomized, double-blind, placebo-controlled clinical trial. Altern Med Rev. 2011;16(4):348-354.
- Chung KF, Lee CT, Yeung WF, et al. Sleep hygiene education as a treatment of insomnia: a systematic review and meta-analysis. Fam Pract. 2018;35(4):365-375.
- Hale L, Kirschen GW, LeBourgeois MK, et al. Youth screen media habits and sleep: sleep-friendly screen-behavior recommendations for clinicians, educators, and parents. Child Adolesc Psychiatr Clin N Am. 2018;27(2):229-245.
- Winkelman JW. Overview of the treatment of insomnia in adults. Literature review current through February 2020. UpToDate. Available at: https://www.uptodate.com/contents/overview-of-the-treatment-of-insomnia-in-adults. Accessed December 9, 2019.
- Talbot LS, Maguen S, Metzler TJ, et al. Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: a randomized controlled trial. Sleep. 2014;37(2):327-341.
- Morgenthaler TI, Auerbach S, Casey KR, et al. Position Paper for the Treatment of Nightmare Disorder in Adults: An American Academy of Sleep Medicine Position Paper. J Clin Sleep Med. 2018;14(6):1041-105
Lana Ferris is a 4th-year naturopathic student attending National University of Natural Medicine (NUNM). She is currently interested in addiction medicine, primary care, and mental health. In her free time, Lana enjoys cooking, paddle-boarding, and singing.
Jennifer Brusewitz, ND, graduated from the National University of Natural Medicine. She currently practices in Portland, OR, and serves as academic faculty at NUNM and as a clinical supervisor at NUNM’s teaching clinics. She also investigates and implements quality assurance standards for the university’s dispensary.