”The best cure for insomnia, is sleep.” (W.C. Fields) If it were only that simple.

Sleep has a stigma associated with it, perhaps several stigmas.  We reward or envy those who only “need” 4 hours of sleep to function.  We celebrate “pulling an all-nighter” to meet a deadline or cram for a test. And, we elevate those who churn out work day and night as go-getters or accomplished people. 

The opposite of these situations is actually true.  Up to 30% of Americans are suffering from insomnia, and not by choice.  The results aren’t amazing stories of productivity, rather they are ones of disease, mental illness and lost productivity at work. They are injury from increased accidents at work and driving, or a 60% increase in health care spending in those with insomnia. (1)  Loss of sleep is having a profound impact on our lives and dragging people down with it.

So, what exactly is insomnia?  It is difficulty falling or staying asleep, non-restorative sleep, and lasting for at least 4 weeks.  Most of the time, insomnia is not a lone diagnosis.  It is secondary, or comorbid, with other diagnosis.  The most common one? Mental health. Insomnia is associated with depression and anxiety at a strikingly high rate of 40%. Even more interesting, insomnia is found to actually precede these illnesses. (2) Often, patients attribute their insomnia to their depression, and think if they could just relieve that depression, maybe they could sleep better. In reality, both need to be treated. (3)  Evidence shows that treatment of depression often does not provide sufficient sleep remedy.  Also, poor sleep actually predicts suicidality, self-harm, more severe depression and poor response to depression treatments. (4)

The National Institute of Health State of Science Conference argued for labelling insomnia “comorbid insomnia” to encourage attention and direct treatment.(5) Treatment goes beyond common sleep hygiene discussion, such as keeping the bedroom cool and dark, or not drinking caffeine too close to bedtime.  Fortunately, there are many approaches to insomnia that many have not considered. Rubin Naiman, PhD, a renowned sleep expert, simplifies his approach by calling attention to sleep promotion and “noise” reduction. He states that rather than taking something to sleep, let go of something to allow sleep.  Our natural default is to sleep, and what works against that is hyperarousal, or noise.  The following sections of “Sleep Promotion” and “Noise/Hyperarousal Reduction” are paraphrased from his chapter in the textbook Integrative Medicine, by David Rakel, MD. (6)

Sleep promotion

               Taking something to sleep does little to change the underlying issue of hyperarousal, rather overcomes this by increasing the sleepiness. First, let’s point out what does not work: alcohol, over the counter antihistamines, and prescription sedative-hypnotics.

What to avoid:

Alcohol does make you drowsy and speed up onset of sleep. However, as it is metabolized it actually increases arousal and disrupts sleep. Antihistamines reduce REM sleep and have a long half-life and significantly contribute to daytime grogginess the following day, among other side effects.  Benzodiazepines decrease deep sleep. Other prescription sleep medications, such as zolpidem (Ambien) or eszopiclone (Lunesta) disrupt sleep cycles, produce amnesia of a poor night’s sleep, increase daytime grogginess, and may cause dangerous autonomic behavior, such as cleaning, cooking or driving at night with no recollection of the events.

Options to try:

Melatonin encourages a natural descent into sleep and won’t override significant noise. It triggers GABA and a cascade leading to sleep and dreaming. It is also coupled to reducing core body temperature, a factor for effective sleep.  For many, a low dose of 0.3 mg – 0.5 mg taken 30 -120 min before bed is sufficient.  Interestingly, many commercial preparations are higher, 2-3 mg per dose. Thankfully, it has a good safety profile, but is contraindicated in pregnancy. It can be taken in a sustained release form also.  A liquid tincture form allows it to absorb via the oral mucosa for a faster onset and may be useful for nighttime wakening.

Valerian Root is a mild anxiolytic and hypnotic that is more helpful for chronic insomnia.  It is often necessary to take nightly for up to 2-3 weeks to see an affect. Consult your physician if planning to take it as there is caution with pregnancy, drug-herb interactions, and those with liver disease.

Hops, best known for its’ use in beer, refers to the flower clusters on the plant Humulus lupulus. It is helpful for insomnia and has some evidence for relieving muscle tension and alleviating some menopausal symptoms.

L-theanine has some limited research for use with insomnia.  Animal and anecdotal studies have shown help with anxiety, hypertension, sleeplessness, and managing stimulant effects of caffeine.

Nutrition supplements. Deficiencies can contribute to insomnia; a common cause is vitamin D deficiency. 

Noise/Hyperarousal reduction

This noise is cumulative. If you ate a spicy meal, had a fight with a loved one and your bedroom is extra warm, you are more likely to suffer sleep problems than if only one of these issues were present. We can break down hyperarousal into 3 distinct areas:

Body: Many issues with our health can interfere with sleep. Some more obvious include pain, depression, anxiety, gastric reflux, restless leg syndrome, obstructive sleep apnea and caffeine intake. Some less obvious include nutrient deficiencies, medication side effects, poor stress management, and inadequate physical activity. Address these issues at the same time as your insomnia.

Mind: The goal is to decrease psychological and behavioral input of hyperarousal.  An easy way to explain these is to follow the basic outline of cognitive behavioral therapy for insomnia (CBT-I).

• Sleep Hygiene methods include commonly discussed factors.  Keep your room dark, get enough daytime exercise, control substances you eat or drink.  Have a daily ritual without devices to unwind and signal your body it is time to sleep.
• Dysfunctional thoughts distort the truth.  For example, we may tell ourselves “I will have a terrible day if I do not sleep well tonight” Or “I must get myself to sleep”. This will increase anxiety and arousal.
• Time in bed needs to be associated with sleep.  Laying in bed awake for over 15-20 minutes will decrease your mind’s association of the bed with sleep.
• Relaxation practice reduces our sympathetic, or excited, tone which helps our bodies and mind ease into rest.  Common ones include meditation, short breathing exercises or progressive muscle relations exercises.
• Restore healthy REM sleep. REM sleep is associated with dreaming, which we need to consolidate memory and process emotions. Many sleep aids actually reduce this important part of sleep, such as antihistamines, alcohol, and prescription sleep aids. Encourage yourself to remember dreams and eliminate things that keep you from dreaming.

Bed: The bedroom environment should be free of things that will interfere with your sleep. Create a sense of sanctuary, meaning it is a stress-free and work-free zone. Let’s answer a few questions.

• Can you hold off texting or scanning emails right before you go to sleep? 
• How about holding off watching a dramatic movie just before you drift off?
• Can you reduce the amount of light in your room with darker curtains or turning clock faces away from you?
• How is the air quality on your room?
• Are you at peace with your sleep partner?

We cannot oversimplify sleep disorders, rather call attention to it. Treatment often needs to include multiple approaches. There is help. There are sleep experts that have amazing ways to deliver explanations and help.  If you have insomnia, maybe check out their websites, see what resonates with you, talk to your doctor, and perhaps even seek out a sleep specialist for advanced diagnosis and treatment. (5)

We need to be looking at insomnia from a different perspective.  Insomnia needs to be treated alongside other diagnoses. Sleep disruptions need to be discussed and treated first in those who don’t yet show other conditions. Difficulty sleeping also needs to be discussed and questioned by every doctor. Adequate sleep is vital for many life functions, decreased morbidity and mortality and quality of life.  It’s time we take sleep more seriously.

For more information click for our handout on “7 Strategies for Serene Sleep” or visit Dr. Naiman’s website for videos, podcast and articles.

Cindy Van Praag, MD

Resources:

1. Roth, T. Insomnia: Definition, Prevalence, Etiology, and Consequences. Journal of Clinical Sleep Medicine Supplement to Vol. 3, No. 5, 2007 S7-S10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1978319/pdf/jcsm.3.5.s7.pdf
2. Rakel, D. Integrative Medicine 4^th Edition. Elsevier 2018. Insomnia, p 74-85.
3. Baglioni, C et al. “Sleep and mental disorders: A meta-analysis of polysomnographic research.” Psychological bulletin vol. 142,9 (2016): 969-990. doi:10.1037/bul0000053 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5110386/
4. Asarnow, L. Cognitive behavioral Therapy for Insomnia in Depression. Sleep Med Clin 14 (2019) 177–184 https://sci-hub.tw/10.1016/j.jsmc.2019.01.009
5. National Institutes of Health State of the Science Conference Statement Manifestations and Management of Chronic Insomnia in Adults June 13–15, 2005  sci-hub.tw/10.1093/sleep/28.9.1049
6. Asarnow, L. Cognitive behavioral Therapy for Insomnia in Depression. Sleep Med Clin 14 (2019) 177–184 https://sci-hub.tw/10.1016/j.jsmc.2019.01.009
7. Rubin Naiman, PhD. https://drnaiman.com/