Pre-Sleep Anxiety is the weird brain state that we can get in to specifically when we are trying to go to sleep, negating the sleep we are desperate for. There is a neurological neurochemical reason for why this happens, and there are some things you can do about it.
Pre-Sleep Anxiety Looks Like
Pre-Sleep Anxiety can look like ruminating on a thing we may have done poorly today, or last week, or last decade.
Pre-Sleep Anxiety can look like trying to solve a real or imagined problem.
Pre-Sleep Anxiety can look like suddenly having inspiration on a brand new thing an wanting to get up and do it… right now.
Pre-Sleep Anxiety can look like being super self critical (negative self talk), feeling very alone, or very sad.
Why do we do this to ourselves?
This is not a trauma response. This is a neurochemical process. This is our brain trying to produce enough noradrenaline and melatonin to go to sleep.
Neurotransmitter Basics: Noradrenaline and Melatonin are needed for sleep
Both noradrenaline and melatonin need to be created in our brain from protein amino acids in our blood for us to go to sleep. If we are too low in noradrenaline, then to help make a bit more our thoughts and feelings kick in with Pre-Sleep Anxiety, stressing ourselves to coax some extra neurotransmitter release, primarily adrenaline with secondary noradrenaline.
This is how we compensate for low noradrenaline during the day, which often feels like anxiety or anger. This is not a good solution for sleep though, as that primary stress release of adrenaline cancels the melatonin, so we now have noradrenaline and adrenaline instead of noradrenaline and melatonin. The melatonin is what pushes our brain “into a sleep ready” state.
Neuronal adrenaline and noradrenaline are subtly different [Neurology LINK]. Adrenaline in the brain is used as a neurotransmitter to handle life emergencies (like running from predators), while noradrenaline in the brain is mostly used to detect threat, manage mood and connect ‘wanting’ to ‘actions’. We don’t want to fall asleep during an emergency, so adrenaline cancels out melatonin, the get “into a sleep ready” state neurotransmitter.
Autistic and ADHD people often have difficulties regulating noradrenaline, where 8 out of 10 are low, 1 out of 10 are high, and rarely is the noradrenaline production neurotypical like average.
Neurochemistry Deep Dive: Why we need enough noradrenaline
For sleep, we have two different groups of neurotransmitters that we need to get our head around. The Dopaminergic Group and the Seratinogic Group.
Dopaminergic Basics
Our brains converts the protein amino acid tyrosine, from our blood, into Dopamine, then we convert that Dopamine to Noradrenaline, and then we convert that Noradrenaline to Adrenaline. Parts of our brain store each of these neurotransmitters in reservoirs, and then release these neurotransmitters as we need them for specialised tasks.
Noradrenaline is used in our brains to asses the situation both in front of us and the near future for risk or opportunity, returning the answer in the form of a mood. It also connects the desire to do a thing to the actions to do that thing. When the noradrenaline is out of the ideal levels, we get insufficient answers to risk and opportunity, so our brain defaults to assuming risk and so we feel anxious or angry. If our noradrenaline is low, we can’t engage the “action” part of our wants.
When we feel anxious or angry, our brain assume we are in danger, and it release reserve adrenaline to manage the emergency. Our brain can substitute this adrenaline for noradrenaline, to get things done. Unfortunately, this doesn’t help our situation assessment, so we still feel anxious and angry.
Serotonergic Basics
Similar to the Dopaminergic process above, our brain converts the protein amino acid tryptophan to Serotonin, and then when it becomes dark, converts Serotonin into Melatonin, which we use to trigger the “sleep state”.
Serotonin does two major things. Firstly, serotonin powers the part of the brain that balances the other neurotransmitters, kind of like an overseer. This is why GP’s often start with something to help serotonin levels. This can fail if your brain can’t make enough without additional help, such as ADHD. The second thing that serotonin does is gives you a pause between trigger and reaction, which can enable you to make a different choice.
Melatonin, as stated, prompts the brain to stop being so awake and go to sleep. It isn’t a sedative, like some chemicals, it just prompts “go to sleep”.
Monoamine Oxidase – why you need enough noradrenaline
Monoamine Oxidase (MAO) is the enzyme we use to metabolise the dopaminergic and Serotonergic neurotransmitters [MAO Wiki LINK], and part of how we turn one neurotransmitter into another. We aren’t going into exactly how that happens here. This is the “mop up” process, ideally once we have used the neurotransmitter for its purpose, but this also manages and gets rid of excess neurotransmitter. There are two different MAOs, A and B, written as MAO-A and MAO-B. Got to love those names.
The same MAO that helps turn Serotonin in to Melatonin also metabolises Noradrenaline. What that means is that as the lights go down and you start to decrease the cognitive load (less complex tasks in preparation for sleep), your brain starts to make Melatonin from Serotonin, and as a side chemical reaction, your Noradrenaline levels go down. This is fine if you have enough Noradrenaline that a bit of a drop just prompts you to want to do less – in fact, that’s really handy for going to sleep. It isn’t good if your Noradrenaline levels go low enough that your brain thinks you are in deficit – that prompts your Serotonin fed Neurotransmitter Manager to throw some moods at you to kick start making more Noradrenaline, which leads us to have Pre-Sleep Anxiety. [PDF LINK, p161-2]
Pre-Sleep Anxiety Intervention
Medication
If you are frequently struggling with Pre-Sleep Anxiety, and it is not directly linked to a specific incident that resulted in a diagnosis of PTSD (and even often if it did) then you will likely need medication to help manage the pre-sleep Noradrenaline variance.
The most common medications that help with this
Melatonin
Most neurotransmitters cannot be ingested by a tablet as they do not pass the Blood Brain Barrier. Melatonin is an exception. The medication provides you with the Melatonin that is identical to the Neurotransmitter that you create to switch your awake and sleep state. Melatonin is very safe, but you should still check with your medical professional to check if this is suitable for you.
This can be available from your chemist in doses generally around 1-2 mg, often with a script from your doctor. You can also have compounded melatonin at much higher doses, depending your specific neurology.
We have an extensive discussion about Beating Insomnia [LINK], which includes how best to use Melatonin.
- Take it 30 minutes before you go to sleep
- Wind down your activities to avoid adrenaline rushes
- You may need some background noise and mild distractions
Agomelatine
Agomelatine is an interesting medication that helps your brain to produce a bit more melatonin with minimal Pre-Sleep Anxiety. It also has some positive next day benefits to general anxiety, social anxiety and depression for many people.
Unfortunately, in Australia, it isn’t covered by the PBS (government assisted costing for medication).
Clonidine
Sometimes the problem with Noradrenaline is that it is too high, and this can cause very similar symptoms to low Noradrenaline. Clonidine is a good medication to start with for decreasing anxiety spikes and wind back the adrenaline response a bit. This medication has downstream positive effects for some sub-variants of ADHD.
Vitamins
If you are deficit in Iron, Vitamin B6 or Vitamin D, this can complicate your ability to sleep, and sometimes that can be mistaken for Pre-Sleep Anxiety. Your GP can give you a blood test to confirm if this is the case.
If you are suspected of or diagnosed with either Autism or ADHD, please note that Iron and B6 are a bit more complicated than for neurotypical people.
- Iron aka Ferritin: Iron is a key ingredient to making neurotransmitters, including Dopamine, Noradrenaline, Adrenaline, Serotonin and Melatonin. Iron deficiency and increased behavioural difficulties, sleep difficulties and restless legs is well documented with ADHD [LINK] and Autism [LINK].
- Neurotypical people seem to do well enough with 30 ng/mL of blood ferritin, and generally your GP will only inform you if your pathology results are lower than this. Specifically ask what your ferritin score is, and try to get it higher than 50.
- Improve your iron by eating meat (any will do, beef has twice as much available iron as fish meat, so adjust your quantities as you need), or if vegetarian / vegan ensure you eat enough green leafy vegetables with acetic acid (to help plant iron become bioavailable) while avoiding dairy in your iron meals.
- If your ferritin doesn’t increase, consider iron supplements (beware of constipation, and be careful that vitamin C fortified supplements don’t adversely affect your other medication taken at the same time).
- If you still don’t improve your ferritin, consider an infusion (talk to your doctor).
- ARFID, difficulties swallowing tablets, and needle fears can complicate all of this.
- B6 / Pyridoxine: The most common pyridoxine test by pathology is checking your dietary B6 rather than your body store B6 (p5p). Ask your GP to check specifically for body stores.
- Many GP’s will just do a Vitamin B12 test and assume that your B6 is in line with that (for complicated reasons), and for most people this is good enough. However, for people who have B12 supplements (eg vegans) and for people diagnosed with Autism (many have low absorption for B6, B9 and B12), assuming that B12 levels will be in line with B6 is an error [LINK].
- To improve your B6, you can try eating more foods with B6 (such as banana), or supplement via vitamin supplements. Chronically low levels can be addressed medically.
Sleep Routine Hacks
Take a look at our existing information on Beating Insomnia [LINK]. In this we discuss, in detail, facts and fictions around sleep, and how to improve your sleep.
Specifically, look to the section around
- Dimmer lights
- Calming but interesting activities
- Medication as appropriate, including Melatonin
- Pre-Sleep Adrenaline Activities
- Journaling
- Noise, and
- Meditation
The goal in your Sleep Routine Hacks is to keep your adrenaline response moderate to low, but not too low, before you go to sleep.
Additional to the information in the Beating Insomnia page, you may benefit from doing some cardio exercise before or just after dinner. Not only does this increases your fitness, it increases your adrenaline and noradrenaline several hours before you go to sleep, which means that it will be a little higher when you do want to go to sleep, which avoids the anxiety that your system uses to boost the Noradrenaline to help make Melatonin.