“Unremitting, disabling, constant, pervasive, and pernicious”1 are adjectives used to describe insomnia. According to the National Institutes of Health, 60 million adults in the United States struggle with insomnia every year.2 Its prevalence increases with age and is also more common in women.3 Insomnia is more than a sleep problem, as those who suffer from it have also been found to experience increased levels of chronic pain, cardiovascular disease, cancer, obesity, diabetes, endocrine and immune dysfunction.4

There are 3 broad categories of causative factors commonly referred to as the “3 Ps”: 1) predisposing factors, 2) precipitating factors, 3) perpetuating factors.

Predisposing factors are those variables that interfere with a normal circadian sleep cycle. For instance, consumption of alcohol, caffeine, nicotine, disorders such as restless leg syndrome, acid reflux, sleep apnea, shift work, jet lag, etc. These factors set the stage for individuals to go on to develop insomnia.

Precipitating factors are the triggers that flip the switch towards insomnia. Examples include stress associated with family, occupation, health challenges, etc.

Perpetuating factors refer to behaviors intended to compensate for sleeplessness that inadvertently keeps the show going. These include excessive wake time in bed, napping, dozing, anxious attempts to control sleep, etc.5

In most instances, insomnia does not result from insufficient sleepiness since most individuals are truly exhausted. Instead, insomnia seems to be a product of excessive wakefulness. Most conventional sleep medications temporarily suppress the neurophysiological symptoms of hyperarousal but they do so with risk. Their side effects include development of tolerance, dependence, damaged sleep architecture, morning hangover, amnesia, rebound insomnia, cognitive impairment, etc.

In contrast, botanicals and nutraceuticals provide less of a knockout and assist sleep more gently with significantly fewer adverse effects. These agents included melatonin, valerian root, hops, L-theanine, lemon balm. A multidimensional therapeutic approach also incorporates improvement of sleep hygiene (e.g. by managing alcohol/caffeine use), review and optimization of any necessary medications, and management of depression and chronic pain, etc.

Additional lifestyle modification focuses on using phototherapy to better manage exposure to light/darkness, maintaining a regular sleep-wake pattern, dimming the lights 1-2 hours before sleep, sleeping in complete darkness, establishing the bedroom as a stress- and work- free zone, limiting exposure to stressful imagery from books/television, and concealing any clocks in the bedroom. Finally, other factors to consider include exposure to pesticide-laden fabrics in bedding, synthetic material in some mattresses and pillows, and off-gassing from furnishings/carpeting.

Obviously managing insomnia in this manner requires a more time-consuming investment from the client compared to simply prescribing a pill. However, our method works well over the long-term, does not risk side effects, and ultimately treats the underlying cause which may have been causing more than just insomnia.

  1. S.E. Matteson-Rusby, W.R. Pigeon, P. Gehrman, et al.: Why treat insomnia?. Prim Care Companion J Clin Psychiatry. 2010 12
  2. National Institute of Neurological Disorders and Stroke: Brain basics: understanding sleep. NIH publication no.06-3440-c 2007 05.07.11
  3. E. Mai, D.J. Buysse: Insomnia: prevalence, impact, pathogenesis, differential diagnosis, and evaluation. Sleep Med Clin. 3:167-174 2008
  4. D.J. Taylor, L.J. Mallory, K.L. Lichstein, et al.: Comorbidity of chronic insomnia with medical problems. Sleep. 30:213-218 2007
  5. M.L. Perlis, M.T. Smith, W.R. Pigeon: Etiology and pathophysiology of insomnia. M.H.Kryger T. Roth W.C. Dement Principles and Practice of Sleep Medicine. ed 4 2005 Saunders Philadelphia 714-725
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