Notes from lectures at Virginia University of Integrative Medicine, Dr. Seung Choi and Dr. Hyungsuk Choi. Summer 2024, Mental health and Trauma.

Insomnia	
Requires on-going management.	
Each patient is unique. Everyone’s insomnia is one of a kind.	
Key is finding the underlying reason behind it.	
It is a result of many conditions and reasons.
Acute insomnia: few days to a few weeks	job loss, death in family, moving, stress
	Return to normal sleep pattern after trigger disappears
Chronic Insomnia	difficult sleep 3 times per week present for three months
	Cause: stress, depression, anxiety, medications, health conditions
Non-Pharmacological Treatment	
Sleep Deprivation Therapy	Behavioral treatment by limiting time in bed to actual sleep time.
	Reduces variability in sleep schedule
	Strengths sleep/wake system controlled by circadian pacemaker
	Reduced time in bed increases homeostatic sleep drive and regulation
	Leads to short sleep onset latency, reduced wake time after sleep onset
	helps to reset body’s sleep-wake cycle for consistent, higher-quality sleep
	challenging at first due to increased daytime sleepiness.
Cognitive Behavioral Therapy for Insomnia (CBT-1)	helps identify and replace thoughts and behaviors that cause sleep problems
	Techniques- cognitive therapy stimulus control, sleep restriction,
	sleep hygiene, and relaxation training.
	First line of treatment for chronic insomnia, effective, no side effect.
Relaxation techniques	Reduce physical and mental tension. Reduce racing thoughts and anxiety.
	Techniques: tense and relax different muscle groups, deep breathing to calm,
	meditation, guided imagery like peaceful scenes.
	Regular practice improves sleep quality and duration after time.
Sleep Hygiene	Practice and habits that promote good sleep and daytime alertness
	Maintain and consistent sleep pattern
	Create a comfortable sleep environment
	Avoid stimulants like caffeine and nicotine after lunch
	Limit screentime before bed.
	Engage in more exercise but not near bedtime.
	Managing stress and developing a relaxing pre-sleep routine.
	Forms the foundation for healthy sleep pattern.
Circadian Rhythm	
Insomnia management from body temperature to hormone	
Internal biological clock, body temperature fluctuations, and hormone cycle.	
Core Body Temperature rhythm	Distinct 24-hour cycle: peak 11 hours after waking and lowest 22 hours after waking
	Tied to sleep propensity, the force behind the urge to sleep.
	Core temperature falls in the evening, deep sleep core is at its lowest, in early morning.
	Temperature control: Create a sleep environment that allows the body to cool.
	Adjust home temperature or use breathable bedding.
	Exercise: more in the morning or afternoon, not late, it can raise body temperature.
	Try to avoid hot baths at night. Have a 1-2 hour cooling process at night.
Hormone Rhythms (Cortisol, Serotonin, Melatonin, Growth Hormone)	Melatonin makes you sleep, it is produced by sunlight in the day
	Cortisol makes you more alert and is produced by stress.
	These two hormones work in opposite cycles.
	Melatonin rises, cortisol falls, and cortisol rises, melatonin falls.
	Circadian rhythm is cortisol in the morning and melatonin at night.
	Lack of sunlight in the day leads to a lack of melatonin at night.
	Cortisol does not decrease at night due to lighting and stimulating activities.
	This causes Delayed Sleep Phase Syndrome: sleep 2 or 3 hours after midnight.
DSPS- Delayed sleep phase syndrome	Fail to sleep at socially acceptable times, not drowsy until after midnight
	Challenge when waking up for work, school, and other daily obligations
	Prevalent in adolescents and young adults.
	Chronic sleep deprivation causes daytime fatigue, decreases productivity, mood disturbances
Cortisol	Stimulating activities push the circadian rhythm back, cortisol not released in morning causing:
	Fatigue, digestive disorders and abdominal bloating.
	Cortisol in the morning helps to prepare you for daily battle and active engagement
	Chronic Fatigue syndrome is a lack of cortisol secretion
	If morning bowel movement delayed or appetite until noon- cortisol secretion problem.
	The biological rhythm recovers at noon for bowel movement, increases appetite, and alertness.
	They become clear-headed at night, fall into a vicious cycle.
Melatonin	Evidence supporting supplements is insufficient. There are few benefits to it.
	Naturally produced by sunlight exposure to eyes and skin. 20 to 40 minutes a day.
	Melatonin and body temperature have an inverse relationship.
Seratonin	Calming and relaxing effects that help with insomnia
Growth hormone	Repairs the body during sleep
Circadian rhythm	Is corrected by regular lifestyle
	Wake-up time: get up even if tired
	Mealtimes- Feasible planning
	Time exposed to sunlight in morning and day.
	Not to exercise late at night.
Antagonistic activity of Frontal and Parietal lobes of brain	Advised to avoid complex mental activities before bedtime
	Front lobe is higher-order cognitive functions like planning, decision making, thought processes
	Parietal lobe is involved in processing sensory information and spatial awareness.
	High activity in one will cause low activity in the other.
	Sensory tasks can help quiet the mind by suppressing the frontal lobe.
	Sensory tasks can be focused on repetitive physical sensations (like tapping foot), or
	Simple visual or auditory stimuli shifting racing thoughts to sleep-ready state.
	Meditation on a single point to help “let go’ of distracting thoughts.
	Do not force self to sleep, do relaxation things, simple sensory tasks to quiet the mind for sleep
12 sleep Hygine Rules that work: regulate body temperature and hormones	notes:
1. Wake up same time every day. Do not sleep in, even holidays and weekend	helps to reset biological clock, helps insomnia long-term
2. Get natural sunlight exposure in the morning. 20 to 30 minutes.	Avoid checking emails and social media first thing in morning.
3. Raise core body temperature in the morning. Exercise, eat breakfast, shower.	
4. Do not eat late at night. Finish several hours before sleep.	
5. Never lie in bed when awake, bed is only for sleep or sex.	
6. Remove all electronic devices and stimulating activity from bedroom.	
7. Do not get up to check the time in night. Do not dwell on lack of sleep.	
8. Try to lie down to sleep at a fixed time each night. Never force sleep	Engage in calming activity. Sleep is a passive process when conditions are right.
9. Exercise 11 hours after awake, let body temp cool at night.	
10. Take only short naps like 10 to 30 minutes.	Long naps make sleeping harder.
11. Never take sleeping pills because you are worried or tryting to force sleep.	Medication is to reduce suffering. Use sleeplessness as a leisure time for things you have no time for.
12. Do not tell people you have insomnia like bragging about it.	Do not fixate on labeling self a insomniac.
Acupuncture	Acupoints
Treat the imbalance of energy, yin and yang, channels.	Insomnia: Ht7 shenmen, SP6 Sanyinjiao, Anmian (peaceful sleep)
Heart and Kidney miscommunication	Kd3 Taixi and Kd6 Zhao hai, BL15 Xinshu, BL23 Shenshu
Stomach Qi disharmony	St36 zusanli, BL21 Weihsu, ST45 Lidui
Spleen deficiency with phlegm	PC6, ST40, GB40
Fire-water control	HT7 and SP6
Heart and Spleen deficiency	BL20 Pishu, BL15 Xinshu, Sp1 Yinbai.
Phelgm heat	ST40 Fenglong, BL19 Danshu, LU5 Chize.
Auricular acupuncture	Subcortex, sympathetic, heart, spleen, kidney, endocrine, shenmen
Cupping	Urinary bladder 1st line
Herbal medicine	
Gui Pi Tang	for Qi and heart blood deficiency, Difficult falling asleep
Tian Wang Bu xin Dan | Huang Lian E Jiao Tang	Heart and kidney disharmony- difficult to stay asleep
Dan Chi San	Heart heat- nightmares
Xiao yao San	Liver Qi stagnation- difficult falling asleep
Wen Dan Tang	Heat and Phlegm- Waking up to early
Chai Hu jia Long gu Mu Li tang	Liver yang rising- tossing and turning from excess heat, difficult to fall asleep
Tian Ma Gou teng Yin	Liver yang rising- irritable, headache, dizziness, vertigo
Huang Lian Jie Du Tang	Excess heat causing insomnia, high fever, thirst, blood heat level.
Suan zao ren Tang	Liver blood deficiency- Restless sleep with many dreams, insomnia
Patient Management	
Treatment duration is at least 3 months	first month symptoms may seem worse until balance is restored
Frequent treatments 1 or 2 sessions a week	Understand their problems, help them relax, help them identify their issues, reflect on self
Patient education: teach them the 12 Sleep Hygiene rules	Encourage patients and check if they are following the 12 rules.
Herbal medicines to help the body’s response	Evaluate the patients pattern and use the right herbal formula.
70-80% of patients show improvement and 10% discontinue sleeping pills.