SLEEPLESSNESS / INSOMNIA

Sleep is as important to promoting optimal health as diet and exercise. It restores and repairs the damage done during the course of the day. However, many of us have difficulty getting a good night’s sleep. Either we’re too busy to sleep or when we try to go to bed, we stay awake thinking or wake in the middle of the night.

Insomnia refers to difficulty falling asleep or staying asleep throughout the night. It is a common condition. About 10% of the population has chronic insomnia and about 50% have significant insomnia at some time. It can be traced to a number of physical, mental, behavioral, and environmental factors

Sleep-onset insomnia refers to difficulty falling asleep. It can be associated with pain, breathing difficulties, stimulant drugs, withdrawal from sleeping pills, irregular sleep schedules, excess alcohol consumption, or emotional disturbances, such as anxiety, phobia, or depression. It can also be associated with sleep disorders such as sleep apnea, a condition in which there is intermittent disruption of breathing during sleep, or delayed sleep phase syndrome, a circadian rhythm disturbance in which the person has delayed sleep and waking times and cannot move to an earlier bedtime without an earlier waking time.

With early morning awakening, there is no difficulty falling asleep but there the person awakens too early. Sleep maintenance insomnia refers to awakening several times throughout the night with either difficulty falling back to sleep or drifting into a restless, unsatisfying sleep.

As a person ages, total sleep time tends to decrease and sleep may become disrupted. The amount of stage 4 (very deep sleep) may decrease. There may be early morning awakening or sleep maintenance insomnia. These two types of insomnia are sometimes associated with depression.

Tendencies to anxiety, self-reproach, and self-punishing thinking are often magnified in the morning and may contribute to early morning insomnia, causing awakening between 3 and 5 am for no apparent reason.

Reversal of sleep rhythm usually reflects a circadian disorder such as jet lag. It may also occur after a head injury. Misusing sedatives or working irregular night shift hours can sometimes cause reversals, as can sleep apnea. With sleep apnea, a person may become drowsy in the morning, sleep or doze much of the day, and have a fitful, uninterrupted sleep at night.

Rebound wakefulness commonly occurs when sleeping pills are discontinued in a person who normally takes heavy doses. This is often wrongly interpreted as a recurrence of chronic insomnia.

A doctor will evaluate sleep pattern, intake of alcohol, caffeine, and nicotine, drug use, degree of psychological stress, work and travel schedule, and level of physical activity. A physical examination and lab tests are usually conducted to identify any underlying medical conditions.

Drugs that contribute to insomnia are oral contraceptives, thyroid medicine, beta blockers, alcohol, nicotine, and marijuana.

Holistic doctors may assess hormone levels. Shifting levels of estrogen and progesterone in women and testosterone in men can result in changes in sleep. Women in menopause often notice sleep disruption due to a decline in estrogen and/or progesterone levels. Women who are taking the drug tamoxifen for breast cancer often experience severe insomnia. They should not take herbs and supplements with an estrogenic effect because they can interfere with the cancer treatment.

Adrenal stress can cause elevated cortisol levels. High night-time cortisol levels have been associated with insomnia.

Difficulty falling asleep can be due to anxiety. Early morning awakening or sleep maintenance insomnia may be related to emotional disturbances such as depression or to a physical disorder such as pain or breathing disturbance during sleep. If there is persistent unexplained insomnia, referral to a sleep lab may help.

Prescription drugs such as Valium, Ambien, Restoril, Xanax, Ativan, and chloral hydrate are often prescribed for sleeping difficulty but they can promote tolerance, dependency, and even addiction. Antidepressants are sometimes prescribed for insomnia.

Diet

Cut out caffeine �?Caffeine consumption can have a pronounced effect on sleep, causing insomnia and restlessness. In addition to coffee, tea, and soft drinks, look for hidden sources of caffeine such as cough and cold medicine and other over-the-counter medicine and chocolate.

Avoid added sugar �?Although sugar can give a burst of energy, it is short-lived and can cause uneven blood sugar levels. This can disrupt sleep in the middle of the night as blood sugar levels fall.

Eat tryptophan-rich foods �?Tryptophan is an amino acid that is a precursor to serotonin, which is then converted to melatonin. Tryptophan occurs naturally in turkey and other meat, milk, cheese, bananas, pumpkin seeds, and legumes.

Diet, cont'd Eat magnesium-rich foods �?Magnesium is a natural sedative. Deficiency of magnesium can result in difficulty sleeping, constipation, muscle tremors or cramps, anxiety, irritability, and pain. Foods that are rich in magnesium are kelp, wheat bran, almonds, cashews, blackstrap molasses, and brewer’s yeast.

Nutritional Supplements

Calcium and Magnesium �?Calcium and magnesium act as sedatives. A typical dose is 600 mg calcium and 250-500 mg magnesium. If you take a daily calcium supplement to meet your nutritional requirements, look for a calcium-magnesium combined supplement in a 2:1 ratio and take it in the evening.

Multivitamin �?There are a number of vitamins and minerals that can help improve sleep quality. Vitamin B6 is required for the conversion of the amino acid tryptophan into serotonin, which helps with sleep. A food source of B vitamins, especially vitamin B6 is 1-2 teaspoons of nutritional yeast. It can be stirred into a glass of juice. Other sources of B vitamins are liver, whole grains, tuna, wheat germ, blackstrap molasses, bananas, and sunflower seeds. Deficiency of iron has been associated with restless leg syndrome. Chromium is often effective when there is waking at night due to blood sugar imbalance.

Melatonin �?Melatonin is a hormone that is produced naturally by the body. The pineal gland in the brain makes serotonin which is then converted into melatonin when exposure to light decreases. Melatonin can help people fall asleep when the bedtime rhythm has been disturbed. In studies, people taking melatonin sleep better, take less time to fall asleep, and feel more energetic and awake during the day. One study found that melatonin may be effective for jet lag, especially long-distance travel. Melatonin has also been suggested for re-establishing regular sleeping in shift workers.

There is no typical dose of melatonin. It is typically taken about 30 minutes before the desired bedtime. Some experts caution that melatonin should not be used in depression, schizophrenia, autoimmune diseases, and other serious illness. Pregnant and nursing women should not use melatonin. Melatonin should not be taken before driving or operating machinery. While melatonin is often recommended for short-term use, the long-term effect of melatonin supplementation is unknown.

Herbs

Valerian �?Valerian (Valeriana officinalis) is a herb that has been long used as a remedy for insomnia. As early as second century A.D., valerian was recommended for insomnia. There are rumors that the name Valium was created to sound like the word valerian. In 1985, it was approved by Germany’s Commision E and is now an accepted over-the-counter insomnia remedy in Germany, France, Switzerland, Belgium, and Italy..

Just how valerian works in the body is still not well understood. Some studies suggest that like conventional sleeping pills, valerian may affect levels of the neurotransmitter GABA. The effects of valerian take between 2 and 4 weeks to become noticeable. A typical dosage of valerian is 2 to 3 g of the dried root, 270 to 450 mg of a 3-6:1 water-based extract, or 600 mg of an alcohol based extract (4-7:1). Valerian is usually taken between 30 to 60 minutes before bedtime. Side effects of valerian may include mild digestive distress. There have been a few cases of mild stimulant effect from valerian use. Valerian usually does not impair driving ability or cause morning drowsiness. Consultation with a qualified health practitioner is recommended to ensure adequate dose and prescription.

St. John’s Wort �?The herb St. John’s wort may help insomnia related to depression. For proper diagnosis and assessment of depression, please see your family doctor.

Kava - Kava is an anti-anxiety herb that may be helpful for anxiety-related insomnia. A typical dose is standardized to contain 210 mg of kavalactones, taken 1 hour before bed. The US Food and Drug Administration (FDA) recently issued an advisory to consumers about the potential risk of severe liver injury resulting from the use of dietary supplements containing kava. To date, there have been more than 25 reports of serious adverse effects from kava use in other countries, including four patients who required liver transplants.

Other herbs - Chamomile, hops, passionflower, skullcap, and ashwagandha are other herbs that are often used for insomnia. Some people may find benefit from simply taking chamomile tea 1 hour prior to bed. Chamomile can reduce anxiety, calm the digestive system, and relieve muscle tension.

Traditional Chinese Medicine

In traditional Chinese medicine, insomnia often stems from kidney energy weakness. This syndrome is not necessarily related to kidney disease in Western medicine. A few signs of kidney energy weakness are low back ache, tiredness and fatigue, and a burst of energy at about 11 pm in the evening. Herbal remedies such as the six-herb formula liu wei di huang are often recommended. Women in menopause often experience this type of insomnia. People who are taking anti-estrogenic drugs such as tamoxifen also experience this type of insomnia, however, they should not take herbal combinations such as liu wei di huang that may have an estrogenic effect.

Ayurvedic Medicine

In Ayurvedic medicine, insomnia is often associated with a vata imbalance. Vata regulates breathing and circulation. People with a vata imbalance often notice irritability, anxiety, and fear with insomnia. One Ayurvedic treatment is the application of oil on the head and feet. For the pitta type, room temperature coconut oil is used, for the vata type, warm sesame oil is applied, and for the kapha type, warm mustard oil is often applied.

Exercise

Lack of exercise can contribute to poor sleep. Muscle tension and stress build in the body. Exercise in the late afternoon or early evening can promote deep sleep that night. However, exercising too close to bed can increase adrenaline levels, leading to insomnia.

Lifestyle

Sleep in a completely darkened room �?Melatonin production is slowed in the presence of light. A completely dark room increases the amount of melatonin made more than a partially dark room. If it is not possible to make the room completely dark, consider using an eye mask at night.

Mind/Body Therapies

Meditation, yoga, breathing techniques and other forms of mind-body therapies may promote deep sleep. Some preliminary studies have found that meditation and yoga for 15 to 30 minutes prior to bed may increase melatonin levels that evening.

Feng Shui

Feng shui, which originates in the Chinese philosophy of Taoism, instructs on how to arrange rooms, furniture, offices, houses, and other arrangements to maximize favorable energy flow throughout living spaces. Here are some recommendations that may help promote relaxing sleep:

Try not to have the bed in a corner of the room. The corners are where energy tends to be stagnant.

Avoid putting your bed next to a window. Energy can be drained this way.

When lying in bed, you should have full view of anyone coming in the door. If you can’t do this directly, hang a mirror to reflect the entranceway.

Try to avoid facing sharp corners from desks, bookcases, and other pieces of furniture.