Reprinted with the kind permission of Cort Johnson and Health Rising
Most people with chronic fatigues syndrome (ME/CFS) and fibromyalgia (FM) know the consequences of poor sleep – the fatigue and pain, the difficulty concentrating, the irritability and more. Sleep is when our body rejuvenates itself; no sleep – no rejuvenation. Given how important sleep is to our health, it’s no surprise that poor sleep is the first symptom many ME/CFS and FM doctors focus on.
The effects of poor sleep go beyond just feeling bad, though. It turns out that poor sleep can have significant effects on our immune system – effects, interestingly, which are similar to what’s been found in the immune systems of people with ME/CFS and FM. There’s no evidence yet that ME/CFS and FM are sleep disorders – that the problems ME/CFS and FM patients face are caused by poor sleep – but depriving the body of sleep can cause one immunologically, at least, look like someone with these diseases.
Why Sleep Is Important for Health: A Psychoneuroimmunology Perspective – Michael R. Irwin. Annu Rev Psychol. 2015 January 3; 66: 143–172. doi:10.1146/annurev-psych-010213-115205.
Irwin begins his review on sleep and immunology by noting the “explosion” in our understanding of the role sleep plays in health over the past decade. First, Irwin demolishes the idea that sleep studies are effective in diagnosing insomnia or sleep disturbances other than sleep apnea. Far more effective than a one or two-night sleep study is a home based sleep actigraph “study” which estimates sleep patterns and circadian rhythms over time and is coupled with a sleep diary.
In fact, Irwin points out that the diagnosis of insomnia in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is based solely on patient reports of difficulties going to sleep, maintaining sleep, having non-restorative sleep (common in ME/CFS) and problems with daytime functioning (fatigue, falling asleep, need to nap). (Problems with daytime functioning are actually required for an insomnia diagnosis.)
Several effective sleep questionnaires exist including the Insomnia Severity Index, which assesses sleep quality, fatigue, psychological symptoms, and quality of life and the Pittsburgh Sleep Quality Index, a 19-item self-report questionnaire that evaluates seven clinically derived domains of sleep difficulties (i.e., quality, latency, duration, habitual efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction).
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The Immune System and Sleep
The immune system is vast and incredibly complex and has its own extensive set of regulatory factors, but is itself regulated by two other systems, the HPA axis and the sympathetic nervous system. Both are involved in the stress response and both are affected in ME/CFS and FM. One – the HPA axis – is blunted in ME/CFS, while the other – the sympathetic nervous system – is over-activated.
Poor sleep, it turns out activates both system. The HPA axis is generally thought to be blunted, not activated, in the morning in ME/CFS patients, but the sympathetic nervous system (SNS), on the other hand, is whirring away at night (when it should be relaxing) in both FM and ME/CFS. (Having our “fight or flight” system acting up at night is probably not the best recipe for sleep.)
Sympathetic nervous system activation, in fact, was the only factor in one Australian study which explained the poor sleep in ME/CFS. The authors of a recent FM/autonomic nervous system study went so far as to suggest that going to sleep with FM was equivalent to undergoing a stress test (!). Heart rates, muscle sympathetic nervous activation, and other evidence of an activated sympathetic nervous system response made sleep anything but restful for FM patients. In fact, the authors proposed sleep problems could be a heart of fibromyalgia.
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Metabolism is a big issue in ME/CFS right now, but guess what? Poor sleep also appears to interfere with producing the metabolic reserves our immune cells need to fight off infections.
We often think of inflammation in negative terms, but the pro-inflammatory cytokines our immune cells produce are necessary to fight off invaders. Reductions of a key pro-inflammatory cytokine called IL-6 during poor sleep hampers our immune system’s ability to destroy pathogens.
Getting your circadian rhythms (sleep and wake times) out of whack isn’t doing you any good either. Having insomnia or altered sleep patterns (very late bedtimes) appears to cause deficits in two hormones (growth hormone (GH) and prolactin) produced during early sleep which enhance T-cell activity and promote pathogen defense. That suggests that anyone with an altered circadian rhythm (i.e. late bedtimes) might want to do their best to get to bed earlier.
While pro-inflammatory cytokine production at night primes the immune system to fight off pathogens, the day time is a different story. Chronic sleep deprivation is associated increased daytime levels of several immune and endothelial factors (IL-6, TNF) and endothelial markers (E-selectin, sICAM-1) that are associated with chronic inflammation.
One study found IL-6 levels actually became flipped in sleep deprived people; they were low at night (thereby hampering their pathogen fighting ability) and high during the day (adding to inflammation).
The situation may be even worse if a sleep deprived person is fighting off an infection. One study found skyrocketing levels of damaging pro-inflammatory cytokines when sleep deprived people were given a toxin (LPS) associated with infections. Those damaging cytokines did not show up in healthy people. That suggested that besides the infection they probably weren’t doing too well at fighting off, sleep-deprived people now had inflammation to deal with.
As it often happens, women seem to have gotten the short end of the stick with immune issues, and it’s no different with sleep. Women appear to be more susceptible than men to inflammation that occurs as the result of poor sleep; it’s women, not men, who show elevations of pro-inflammatory cytokines the day after getting less than eight hours of sleep. (Men show elevations of pro-inflammatory cytokines after getting less than six hours of sleep).
Many people with ME/CFS/FM get too little sleep, but sleeping more than normal, it turns out, is not such a great idea either. People sleeping much longer than normal tend to show the same kinds of elevations of pro-inflammatory cytokines as do people who get too little sleep.
The C-reactive Protein Sleep, ME/CFS and Fibromyalgia Connection
CRP is associated with a variety of inflammatory states resulting from infection, cancer and stress. Increased levels of the inflammatory marker, C-reactive protein (CRP), are increasingly being associated with sleep disturbance.
The CRP – sleep connection is intriguing given Jarred Younger’s preliminary finding of increased C-reactive protein (CRP) levels in a subset of ME/CFS patients and a recent finding of increased CRP in FM.
Those findings might not be so surprising. Ten days or so of partial sleep deprivation in healthy controls caused “robust” increases in CRP levels. In fact, the CRP-poor sleep connection is so robust that simply scoring above five on the Pittsburg Sleep Quality Index (PSQI >5) strongly suggests that your CRP levels are elevated. A huge nurses’ study (n=10,908) found that non-restorative sleep – probably the most common sleep issue in ME/CFS/FM – was associated with increased CRP levels even in these healthy individuals.
The early or innate immune response has long been thought to play a special role in ME/CFS. This immune response involving NK cells, neutrophils, macrophages, dendritic cells and others, constitutes the immune system’s first defense against pathogens. Immune cells involved in the early immune response called monocytes / macrophages also play a key role in producing chronic inflammation.
NK cell activity hits a low during sleep but then begins to rise. That the rise is blunted in people with poor sleep probably comes as no surprise to NK cell challenged ME/CFS patients.
ME/CFS isn’t the only disease associated with NK cell problems; depression is as well and having poor sleep increases your risk of being depressed twofold. Plus, for reasons that are not understood, poor sleep appears to trigger stress and depression initiated reductions in NK cell activity; i.e. if you’re having poor sleep and are under considerable stress or are depressed – it’s likely that your NK cells are punking out when it’s time to defend the body from invaders.
We know that having a chronic illness increases one’s chances of becoming depressed markedly, but so does poor sleep. In fact, Irwin reports that having insomnia for over a year increases your risk of becoming depressed 14-fold. That finding is leading some of the more progressive psychologists to focus on preventing or ameliorating sleep problems.
Sleep disturbance also induces a shift toward a type-2 immune response often seen in ME/CFS and in allergic and autoimmune diseases. Just one poor night’s sleep the night before a person is given a vaccine is enough to markedly reduce the effectiveness of that vaccine. A study showing just how frighteningly malleable the immune system can be to stressors such as poor sleep found that a 50% reduction in the effectiveness of an influenza vaccine persisted over a year. Even after three doses of the vaccine and a booster shot were given, adults getting fewer than six hours of sleep a night still received less protection from a hepatitis B vaccination than normal.
The common cold, of course, is no joke to some people with chronic fatigue syndrome (ME/CFS) and FM when it lingers and lingers. Studies suggest that poor and fragmented sleep – which is, of course, common in ME/CFS/FM – significantly increases one’s susceptibility to the common cold. If you’re catching a lot of colds or if they linger and linger, poor sleep could be one reason why.
What To Do?
OK – so poor sleep places a big hurt on our immune system’s effectiveness. What to do about it? No studies, unfortunately, have examined the effect of sleep drugs on immune factors so we’re not going to go there.
Several studies have, however, assessed the efficacy of stress reduction therapies. Dr. Irwin notes reports that practices such as cognitive behavioral therapy, Tai Chia and yoga, which tamp down sympathetic nervous system hyper-arousal, can help improve immune functioning. Tai chi has even been found to improve vaccine effectiveness and reduce inflammation.
Other studies point to the ability of mindfulness based meditations and/or yoga to reduce the cytokine levels and pro-inflammatory gene expression caused by poor sleep. One remarkable study showed a 50% reduction in CRP levels in insomnia patients after a year of cognitive behavioral therapy.
Poor sleep, then, doesn’t just make you feel tired and irritable; it takes a pretty good whack at your immune system, as well. Getting better sleep through better sleep hygiene, supplements (melatonin), calming botanicals (valerian root, L-theanine, passiflora, Melissa, Scutellaria, etc.), stress reduction techniques (meditation, mindfulness, meditation), and sleep medications might just give your immune system a boost.
About the Author: ProHealth is pleased to share information from Cort Johnson. Cort has had myalgic encephalomyelitis /chronic fatigue syndrome for over 30 years. The founder of Phoenix Rising and Health Rising, he has contributed hundreds of blogs on chronic fatigue syndrome, fibromyalgia and their allied disorders over the past 10 years. Find more of Cort's and other bloggers' work at Health Rising.