Psychological stress is a pervasive condition affecting most, if not all, patients presenting in clinical practice. A recent mental health and wellbeing survey reported that 15% of Australians reported experiencing high or very high levels of psychological distress,¹ and a further 72% and 64% reporting stress that impacted their physical and mental health respectively.² While the biological impacts of stress can be measured in almost every aspect of human health, its ability to derange sleep patterns is often immediate and debilitating. Poor sleep further compounds the stress response through its influence on mental health, metabolism and immunity. This case study examines the interplay between psychological stress and sleep, whilst incorporating the naturopathic doctrine ‘treat the whole person’ and introduces some unique insights into treatment options.

Initial Consultation

A 45-year-old female presented with a 1-month history of sleep onset and sleep maintenance insomnia. She reported taking one hour to fall to sleep, which was only achievable with the assistance of an audiobook or podcast. The patient would wake between 2 and 5 am and would often not return to sleep once awake. She had small children who often woke her in the night, and she would take up to an hour to fall back to sleep. Her history of stress dated back to childhood, however had recently become elevated due to financial and relationship stress.

A case history revealed:

• Bed-time between 8.30-9.30 pm;
• Significant premenstrual stress (PMS), which was being treated with escitalopram 10 mg daily;
• Sleep symptoms were worsened during her luteal phase, despite the escitalopram;
• Poor sleep hygiene – phone scrolling for 1 hour prior to bed;
• Anxiety symptoms manifesting as restlessness and racing thoughts, and an inability to focus occurring 3 times weekly;
• Eye twitching, which was worsened by poor sleep and stress;
• Diet was of good quality, although included excess caffeine;
• Non-drinker;
• Regular, daily exercise.

Prescription

The initial prescription focused on improving sleep quality and quantity, supporting stress adaptation and creating a positive sleep hygiene routine.

The prescription included:

• A herbal tablet containing Piper methysticum (Kava) root 3.2 g, standardised to kavalactones 50 mg. Dose: 2 tablets half an hour before bed;
• A magnesium threonate powder containing 76 mg magnesium. Dose:  2 scoops half an hour before bed;
• A herbal tablet to support stress adaptation and cognitive function containing Alpinia galanga (Galangal)1.5 g, Ginkgo biloba (Ginkgo) 3.0 g, Bacopa monnieri (Bacopa) 3.0 g, Rhodiola rosea (Rhodiola) 300 mg, and Centella asiatica (Gotu Kola) 150 mg. Dose: 2 tablets with breakfast;

Dietary and lifestyle advice included:

• Avoid screens for two hours prior to bed time;
• Reduce caffeine intake to 1 cup of tea or coffee per day prior to midday;
• Consume a herbal tea using two teabags containing Matricaria chamomilla (Chamomile) and Passiflora incarnata (Passionflower) tea 1 hour before bed.

Follow-Up - 3 Weeks

The patient reported sleep onset had improved significantly. She was falling to sleep within half an hour of turning off the lights without the use of audio books or podcasts. The patient was now waking between 1 and 5 am and not falling back to sleep without the use of more Kava tablets, which left her feeling drowsy upon waking. She reported feeling less anxiety and improved cognition throughout the day. A review of the Chinese body clock indicated that the wake times correlated with the liver and lung meridians. Additional herbal support was provided to address these areas and counter any perimenopausal contributions to her sleep issues.

The prescription was updated to include the following:

• The herbal tablet for stress and cognition was replaced with a liquid herbal formula containing Schisandra chinensis (Schisandra) 30 mL, Silybum marianum (St Mary’s Thistle) 30 mL, Withania somnifera (Withania) 30 mL, and Actaea racemosa (Black Cohosh) 15 mL. Total 210mL. Dose: take 7.5 ml twice daily with breakfast and dinner;
• Commence 15 to 45 minutes of deep, restorative breathwork in the hour before bed;
• Seek the support of a psychologist or counsellor to address the stress and sleep from a cognitive perspective;
• All other supplements, diet and lifestyle advice were continued.

Follow-Up - 7 Weeks

The patient was achieving a solid sleep most nights, with sleep onset taking 15 minutes and generally waking between 5.30 am and 6 am. She reported improved daytime energy rated 9-10/10 and an abatement of her premenstrual symptoms. Daytime cognition and anxiety continued to remain stable.

The patient was advised to continue all herbal and nutritional supplements along with the psychological support for another month. Following a month of stable sleep, she was directed to slowly reduce each herbal supplement and observe any changes to her sleep pattern. The magnesium threonate was continued for another 3 months.

Clinical Reflections

While this case appeared to be a relatively straightforward one of stress, adrenal overdrive and consequently insomnia, imbalances in other body systems continued to drive symptoms until they were also addressed. The inclusion of liver and lung support was crucial to achieving good quality sleep for the patient.  This case demonstrates the holistic nature of naturopathic practice, where careful examination revealed additional body systems requiring attention to elicit a satisfying result.

References

1. Australian Bureau of Statistics. First insights from the National Study of Mental Health and Wellbeing, 2020-21 [Internet]. Canberra: ABS; 2021 December 8 [cited 2024 October 1]. Available from: https://www.abs.gov.au/articles/first-insights-national-study-mental-health-and-wellbeing-2020-21.
2. Australian Psychological Society. Stress and wellbeing in Australia survey 2015 [Internet]. Melbourne: APS; 2015 [cited 2024 October 1]. Available from: https://psychology.org.au/getmedia/ae32e645-a4f0-4f7c-b3ce-dfd83237c281/stress-wellbeing-survey.pdf