Insomnia
By Alice R. Laule, MD
My own personal history of insomnia gives me some insight, although certainly
not all the answers. My first bout of insomnia began in the late 80’s or early
90’s, and consisted of an absolute inability to fall asleep before 1 AM, no
matter when I went to bed. I went to my first American Holistic Medical
Association meeting in 1991, and because it simply was not readily available,
did not drink my morning mug of coffee. I slept like a baby! At one of the
lectures at that meeting, I learned that as we age our metabolism slows down
and it can take more than 16 hours to metabolize caffeine. It was evidently
remaining in my system until 1 AM. Ordinarily caffeine stays in the system for
6-8 hours, so my 9 AM mug of coffee should have been gone.
I hear many, many patients tell me that they can drink coffee all day, even
have a cup right before bed, and sleep just fine. However, be informed, sleep
studies show that without exception the quality of sleep is poor, less restful than it
could be, while coffee is still in the system. Alcohol also causes poor quality
of sleep, though I know some people feel that the nightcap before they go to
bed helps them get to sleep. The problem with alcohol is an abnormal
wakefulness a few hours after the alcohol wears off.
Insomnia can be divided into two general types, delayed onset of sleep, and
poor maintenance of sleep. Things that work for one form of sleep problem don’t
always work for the other form. Age also plays a role. Teenagers tend to run on
a longer than 24 hour cycle as do people that have been put in environments
where they have no contact with the outdoors. People have been put into caves,
for instance, with only artificial lighting, and allowed to establish their own
cyclic routines. The findings show that most people will settle into a cycle
that is about 25 hours. Teens particularly tend to have a longer cycle, also,
so they tend to go to bed later and later each night, and sleep later every
morning. This is not just a bad habit for them. There is legitimate
neuro-biology causing this problem. Unless they get some help overcoming their
25 hour cycle, disciplining their sleep, this can become a huge cause of sleep
deprivation and difficulties in school.
As we age, the opposite tends to happen, with a tendency to go to bed earlier
and earlier in the evening. Since people in their sixth decade and beyond tend
to need less than 8 hours of sleep a night, this leads to earlier and earlier
awakening, and the perception that there is an insomnia problem. I have
patients who complaint that they awaken at 3 AM and can’t get back to sleep, but upon questioning, they
are going to bed at 8 PM, so they are getting 7 hours of sleep — probably all
the sleep they need.
Early awakening — the person who goes to sleep at 11 PM and awakens at 3 PM and
can’t get back to sleep — is probably the most difficult of the sleep problems
to overcome without pharmaceuticals, in my experience. Several things can
contribute, however, that are easily fixed. One common cause of this,
hypoglycemia, is overcome by changing eating habits. A large carbohydrate
load right before sleep can cause a person to wake up with anxiety about 2-3
hours later. It won’t feel like hunger, or your usual daytime hypoglycemia. It
does feel like your body is awakening you with an alarm signal — which is
exactly what’s happening. If getting up and eating helps you get back to sleep,
consider this possibility. Stop eating carbs before dinner — have a high
protein snack at least two hours or more before sleep time. A bit of yeast-free
Glucose Tolerance Factor form of chromium could be helpful also.
Worry and anxiety, chronic pain, and high levels of alcohol consumption also
account for early morning awakening. There are breathing practices (abdominal
breathing in one form or the other) that can help with anxiety, and also with
pain. The hour of awakening can also be a clue to problems in certain organ
systems. Various acupuncture meridians activate at specific hours on the 24
hour clock. For instance, I just went through a spell of awakening at 3 to 3:30
AM. That’s when the lung meridian activates, quite appropriate as I was getting
over bronchitis at the time.
Sleep onset is a more common problem. In chronic insomnia, this can even cause
such a strong expectation of not sleeping, that when these people go to
bed they immediately begin to worry about not sleeping, which then keeps them
from sleeping. Some sleep specialists advise purposefully depriving yourself of
sleep to overcome this, by getting up very early in the morning, but going to
bed the same time every night, to set your biological sleep cycle. Anti-anxiety
natural substances, like valerian root and L-theanine (an extract from green
tea) can help with this psychological part of sleep onset problems. L-theanine
is also useful for awakening in the middle of the night. About 200 mg. of
L-theanine at bedtime can help. An L-theanine spray is also available to help
that squirrel-cage mind that can wake you up and keep you awake in the middle
of the night. Dr. Vogt and I recently suggested that for a patient for whom we
were having difficulty making a diagnosis of a fairly serious problem. He woke
up with the mind running like crazy on all the ”what if’s”, sprayed the
L-theanine under his tongue, and eventually slept. He told us he was fairly
impressed, because that night “the squirrel was on steroids.”
One of the body’s normal triggers for sleep, aside from the onset of darkness
increasing output of melatonin, is the body begins to cool down. Core body
temperature falls gradually for about 2 hours before we get sleepy. Therefore,
though a nice hot bath may seem relaxing, if you warm up your body too much
with extremely hot water, you will ruin this part of the body’s self-signaling
for sleep.
Since darkness is one of the triggers for sleep, you might assume that staring
at a computer screen or too closely at a TV screen, presenting that kind of
light stimulus to the eyes, might make for sleep delay. In fact, some rather
recent studies have shown that is exactly correct.
As we age, we manufacture less of our own melatonin, so it makes sense to
take some extra about an hour before bedtime. Don’t expect it to “put you to sleep”
like a drug, however. Curiously, one of the most stunning recent findings in
the treatment of autism is how helpful melatonin has been for many of these
children. For children the dose is in the range of 1 mg. For adults, its about
3 mg. Taking amounts larger than 5 mg. at bedtime has no increased
effectiveness. So far, time seems to be proving this to be a safe
supplement. The downside to melatonin is that its duration of action is quite
short. While it may get you to sleep better, it won’t help if sleep maintenance
is your problem. There are sustained release forms of melatonin on the market,
now. There is also a drug (ramelteon) that attaches to the melatonin receptor
which has a little longer duration of action than plain melatonin.
There are many other herbs and supplements that help with relaxation and sleep.
The health food stores are full of them. Here are just a few — chamomile, hops,
valerian (which is also a good muscle relaxant), kava kava, tryptophan, 5-HTP,
GABA, passion flower and catnip. My own experience with kava is interesting,
and backed up by some information I later discovered. Kava relaxes the spinal
cord part of the nervous system, but not the brain. When I tried to get some
help from it, I laid awake just as long as ever, completely alert, but I didn’t
care as much that I was not sleeping . Not everyone has this effect from it. I
have since discovered that it is excellent for me if I have a talk to give, or
some sort of challenging, anxiety producing stress. I am incredibly alert on
kava, but very relaxed. Kava has received a bad rap for causing hepatitis, but
the reported cases were in people who had taken large doses of kava for a long
time. It may also be that the kava root is safer than leaves or stems.
Valerian also receives a bad rap in some of the medical literature, all the
ills and side effects of Valium being attributed to valerian. That’s because
Valium was developed as a synthetic form of one of the components of valerian
root. They are in no way the same thing. No one has ever been shown to be
addicted to valerian, been able to commit suicide on valerian, nor does
valerian cause dangerously deep sedation.
Lavender, the essential oil, also has been studied. The smell of it is sedating
and in fact it has been shown to help with insomnia. I will sometimes put just
a dot of lavender oil on my pillow. This is helpful for both sleep onset and
sleep maintenance forms of insomnia.
After lying in bed for hours and not getting to sleep, most people get pretty
antsy. The rule in good sleep hygiene is that you should get up. Read, do
something relaxing, but get out of bed. Then, be sure you do not let yourself
nap the next day. I realize this is not possible for everyone. People with
some fatigue disorders will not be able to manage without the nap, and some
people are resting in bed even if not sleeping, who will feel worse if they get
up when they cannot sleep. Use your own judgment. Lying in bed tense as a board
and angry about not sleeping certainly is not restful. If you can switch your
focus to prayer, meditation, a breathing practice, something relaxing and
restful, then stay in bed. There is a thing called “sleep efficiency” which is
how many hours you have to stay in bed to get 8 hours of sleep. During the
height (or depth) of my own chronic fatigue syndrome, my sleep efficiency was
horrible! It took about 12 hours in bed to get 6-7 hours of sleep. Curiously
enough, chronic fatigue syndrome and fibromyalgia, while both involving deep
levels of fatigue, also are associated with very poor sleep. Our brain actually
has to flip a switch, so to speak, to sleep mode. It felt like my brain did not
have the energy to flip the switch.
Obviously, keep your bedroom dark, and quiet. Don’t have your desk with stacks
of work on it in the bedroom. Feng shui would say don’t even have your
treadmill in there. Find something very relaxing to do for at least a half hour
before bedtime. Exercise helps, but not too close to bedtime. Remember, the
body has to cool down for two hours. Avoid naps, avoid worry, avoid eating high
carbohydrate snacks or for that matter eating much of anything right before
bedtime. Get away from the computer, cell phone and TV for 30 minutes. If you
read, for heaven’s sakes don’t read a spy novel or a murder mystery that you
can’t put down.
Obviously there are other sleep issues— post traumatic stress disorder, shift
work, sleep apnea, restless leg syndrome, jet lag, and other major illness
associated with loss of sleep — that I have not even tried to discuss here.
It’s a huge topic, and one that retains some mystery despite all of science’s
studies. Why, for instance, is dream sleep so essential to mental health? It is
— even in animals. But why?
Hope your dreams are pleasant ones.