Anxiety disorders plague a substantial percentage of the population. These disorders represent the most prevalent mental illnesses in the world.1 According to data from the National Comorbidity Survey Replication, 19.1 percent of U.S. adults suffer from an anxiety disorder.2 Insomnia is often a comorbidity to anxiety, but it can be present on its own in otherwise mentally healthy people. Many of my patients who are experiencing everyday stress know all too well what it's like to toss and turn all night long.
Anxiety and Sleepless Nights: Role of the Endocannibinoid System
It has become more and more apparent that an imbalanced endocannabinoid system can affect anxiety and sleep. As a reminder, the endocannabinoid system comprises the cannabinoid receptors 1 and 2 (CB1 and CB2), their endogenous ligands known as endocannabinoids, and the enzymes responsible for their synthesis and degradation. The two major endocannabinoids are anandamide and 2-arachidonoylglycerol (2-AG).
Endocannabinoids' effects on anxiety-related responses occur through the CB1 receptor, which is highly expressed in brain areas – such as the prefrontal cortex, amygdala, and hippocampus – that directly regulate emotional behavior.3-4 Knockout mice lacking the CB1 receptor experience increased anxiety-like responses compared to rodents that still possess the receptor.5-6 Deleting the CB1 receptor led to anxiety under stressful conditions.6-7 Benzodiazepine drugs are also less effective in CB1-knockout mice.8
Further evidence the endocannabinoid system is involved in stress is the fact that anandamide is found in the pituitary gland in the morning when cortisol levels begin to spike.9 Additionally, stress is known to increase anandamide levels in human subjects.10
The Role of Cannabidiol in Supporting a Calm Mood
The phytocannabinoid cannabidiol (CBD) is also involved in a healthy stress response, only it achieves its positive actions through a different mechanism. Unlike endogenous cannabinoids, which work on the CB1 receptor, CBD supplementation leads to direct activation of the 5-HT1A serotonin receptor.11-12 CBD's stress-relieving properties are also related to its ability to modulate cerebral blood flow in brain regions involved in anxiety including the amygdala, hippocampus, hypothalamus and cingulate cortex.13
A number of clinical trials have demonstrated that CBD can have a calming effect. Linares and associates observed the effects of different doses of CBD and placebo in 57 healthy male participants performing a simulated public speaking test.14
In this double-blind study, subjects were given oral CBD at doses of 150 mg, 300 mg or 600 mg, or a placebo, prior to the public speaking test. Compared with the placebo, 300 mg of CBD markedly lowered anxiety during the speech. The other CBD doses had no effect, which is consistent with animal studies that show there is a sweet spot in regards to supplementation.
I would note that clinically, not all CBD products are created equal when it comes to absorption and bioavailability, and I routinely find lower doses of highly available CBD work in a superior fashion.
However, Bergamaschi and colleagues found that in patients with generalized social anxiety disorder, a higher dose of CBD (600 mg) before a public speaking test markedly lowered anxiety, cognitive impairment and discomfort in speech performance.15 The placebo group demonstrated higher anxiety, cognitive impairment and discomfort. In patients with generalized social anxiety disorder, CBD has also been found to have a calming effect through modulation of blood flow in certain brain regions and regulation of endocannabinoid levels in the limbic and paralimbic brain areas.11
Cannabidiol & Restful Sleep
The endocannabinoid system is involved in the modulation of the circadian sleep-wake cycle.16 It is therefore logical that CBD has been shown to affect circadian rhythm. Low-dose CBD can be stimulating and promote wakefulness.17 However, higher doses of CBD can be sedating.17 Carlini and Cunha discovered that subjects with insomnia who received 160 mg cannabidiol slept more and awakened less during the night compared with the placebo.17 Low doses of CBD (15 mg), when combined with THC, the psychoactive component of marijuana, are known to counteract THC's sedative effect and promote wakefulness.18
CBD can support healthy sleep both in people with anxiety and mentally healthy individuals. A case study of a 10-year-old girl with post-traumatic stress disorder found that 25 mg of CBD at bedtime and 6 to 12 mg of CBD during the day as needed for anxiety reduced the girl's stress, and improved the quality and quantity of her sleep.19 Furthermore, Babson and colleagues, in a review of the literature, noted that CBD may be useful in REM sleep behavior disorder and excessive daytime sleepiness.20
Closing Thoughts
The endocannabinoid system plays an important role in the stress response and circadian rhythm. The clinical studies investigating CBD's effect on stress and sleep have mirrored what I observe in my clinical practice: This phytocannabinoid can calm mood and, with the right dose, improve sleep.
References
Chronic pain afflicts over 20% of the adult population. Sadly, most MDs have essentially no education in treating pain, beyond offering a few toxic medications. Then they tend to steer people with pain away from those health practitioners who are trained. This puts the acupuncture community on the front lines for addressing this epidemic.
When the body is going through a stressful event, the sympathetic system is activated. This activation will help the body with a life-threatening situation. If this state is activated for prolonged periods of time, it starts to consume energy. These traumatic events that generate stressors in the autonomic nervous system (ANS) will eventually become internalized.
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One of the things that makes acupuncture so difficult to measure is that the medicine actually does contain some esoteric aspects. There have been numerous studies that demonstrate the neurochemical reasoning behind why acupuncture points stimulate the autonomic nervous system to enact change However, not all the benefits of TCM can easily be measured by randomized, controlled trials. But does that make them fundamentally and definitively untrue?
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