No more sleepless nights: dealing with insomnia

by Dr. Jacki Hart

One-third of adults suffer from a period of insomnia each year. In addition, most adults do not get the requisite eight hours of sleep per night that the body needs—the vast majority sleep less than seven hours. Lifestyle changes, however, including relaxation techniques, as well as acupuncture and certain herbs and supplements can help to bring on the zs.

Joyce,* a healthy 43-year-old woman came to my office complaining of awakening most mornings between 3:00 and 4:00 a.m., long before her alarm set for 7:00 a.m. This married mother of three and part-time caterer had no trouble falling asleep, only difficulty staying asleep. Her husband reported that she did not snore (a sign of sleep apnea) or excessively move her legs while sleeping (restless leg syndrome), both of which can contribute to insomnia. Joyce was not taking any medications and my exam revealed no underlying illness or condition that could be responsible for her difficulty sleeping.

Understandably, Joyce was frustrated with this chronic lack of sleep and lack of energy. She felt irritable with her family and inefficient, even ineffective, in both her work and home life.

Joyces particular type of insomnia is called early morning arousal. Other types include difficulty falling asleep (called sleep latency); sleeping very lightly and awakening feeling unrefreshed; and waking up multiple times during the night (called fragmented sleep). With any form of insomnia, many of us, like Joyce, lie in bed not sleeping, tossing and turning, and getting more and more upset that we are still awake. Also similar to many people, Joyce wanted to avoid medications. She was concerned about potential addiction and about feeling "spacey" or drowsy throughout the day.

Sleep-wake cycles are dictated by internal circadian rhythms. These rhythms are strongly influenced by light entering through the eyes, which signals the brain to regulate production of certain hormones including one called melatonin. Circumstances that unnaturally diminish the entrance of light into the eyes can disrupt the natural circadian rhythm, the production of necessary hormones, and, therefore, an individuals proper sleep-wake cycle. Such circumstances include blindness and failing eyesight due to aging. (Note that aging contributes to insomnia through several means including depression, which is common among the elderly; dementia; and increased production of stress hormones such as cortisol.) Traveling to different time zones and developing jet lag as well as working the night shift disturb the natural circadian rhythm as well.

Insomnia can also be a sign of an underlying medical condition such as depression, an over-active thyroid, high blood pressure, heart disease, asthma, sleep apnea, restless leg syndrome, dementia, or pain disorders. In fact, Joyces pattern of sleep disruption—early morning arousal—is commonly seen with depression. However, after careful screening, she did not have any other signs or symptoms of depression. More than anything else, Joyce was living with constant, low-level stress and general nervousness due to her busy, somewhat complicated life.

Several lifestyle factors can contribute to sleep disturbance. Keeping a sleep-wake diary is helpful in identifying and modifying these factors, which include:

• Stress
• Caffeine
• Alcohol
• Eating habits (e.g., eating too late at night)
• Smoking
• Exercise or lack of exercise
• Timing of certain activities (e.g., exercising just before going to bed)
• Excessive time on the computer
• Work-related stress

The most effective and frequently used conventional treatments to establish a restful sleep pattern are behavioral, not medicinal. These include achieving proper "sleep hygiene" as well as making other lifestyle alterations.

Relaxation techniques. A multidisciplinary team, including medical doctors, specializing in sleep disturbances can train and guide people in such approaches as yoga, meditation, deep relaxation, biofeedback, hypnosis, massage, and/or guided imagery. Practicing one of these techniques within 30 minutes of bedtime is particularly helpful.

Acupuncture. This ancient Chinese practice is very effective for treating both stress and insomnia; some reports suggest a success rate for the treatment of insomnia as high as 90%. A typical protocol is to receive acupuncture treatments weekly until a normal sleep pattern is achieved, followed by monthly maintenance sessions. However, a licensed and certified acupuncturist will determine the most appropriate treatment regimen for each individual.

Exercise. Regular exercise is an excellent way to help regulate circadian rhythms and the sleep-wake cycle. It is best performed some time prior to dinner, as exercising too close to bedtime can make it difficult to fall asleep.

Light therapy. For night shift workers suffering from insomnia, light therapy can be quite effective. This therapy involves using very bright lights in the work setting and then, when trying to sleep during the day, doing so in a very dark room while wearing sunglasses.

While some cultures have a long history of using supplements and herbal remedies for the treatment of insomnia, such practices have only gained popularity over the last few decades in the United States and other Western nations. Over this relatively short time, though, certain substances, once popular, have already gone out of favor (for example, L-tryptophan is now off the market in the US due to instances of a rare muscle disorder) or have been somewhat disappointing in light of the initial attention they received (see melatonin below). Those that hold the most promise are:

Lavender. Either sprayed as a mist or used in another form of aromatherapy, lavender aids in a more complete nights sleep, particularly in the elderly. Lavender flower (Lavandula augustifolia) is approved in Germany for oral use as a tea to help soothe the person with insomnia and improve sleep patterns.

Valerian root. The most promising of the botanicals seems to be valerian root (Valerian officianalis). Short term studies—lasting up to two weeks—suggest success in treating some types of insomnia, particularly those related to anxiety, nervousness, or stress, such as a fitful, restless sleep with frequent arousals. Some questions remain, though, including: 1-should valerian be taken indefinitely or only until the cycle of insomnia is broken? and 2-is valerian safe to take for a long period of time?

In my clinical practice, people have had success with valerian for several types of insomnia. The dose recommended by Germanys Commission E (a governing body that reviews the safety and efficacy of herbal supplements) is 2000 to 3000 mg of valerian root extract per day either in one dose or three divided doses. Studies have also found success with 400 mg a night. I generally recommend the latter, lower dose.

Lemon balm. Valerian is thought to be particularly successful when used in conjunction with lemon balm (Melissa officianalis). Lemon balm is approved in both Germany and Great Britain to improve sleep disturbances. When used alone, it should be taken as a loose-leaf tea (1.5 to 4.5 grams per cup of hot water) or dried extract in a capsule (300 to 900 mg). When used in conjunction with valerian root, though, as little as 160 to 300 mg of lemon balm extract has been shown to enhance the effects of valerian.

Other herbs. Other herbs approved in both Germany and Great Britain for mild to moderate sleep disturbances include:

• Passion flower (Passiflora incarnata) - particularly for restless sleep related to nervousness or anxiety. Recommended dose: 2 grams of the dried extract at bedtime in combination with lemon balm and valerian root.
• Chamomile flower (Matricaria recutita) - for mild sleep disturbances. Recommended dose: 3 grams of the tea before going to sleep.
• Hops (Humulus lupulus) - particularly for restless sleep related to nervousness and anxiety. Recommended dose: 300 to 500 mg of dried extract capsules or tea with valerian root.
• Orange peel (Citrus aurantium) - for transient sleeplessness in both children and adults. Recommended dose: 2 grams of tea in boiled water.

Melatonin. Frequently touted as a valuable supplement for insomnia, melatonin has shown only mixed results. It has been valuable for some people who do not fall asleep easily as well as for temporary sleep disturbances from a change in schedule (daytime work to nighttime) or sudden disruption of the circadian rhythm as with jet lag.

Melatonin may also be helpful for people on a certain class of medications called beta-blockers, used for high blood pressure and heart disease. This supplement is not effective in the elderly, but does work for people with schizophrenia who frequently suffer from insomnia. Among my patients, many say that they had success for the first three to five days; after this time, though, the benefits wore off. The effects of melatonin are very individual. Speak with your doctor if you would like to try it, particularly because there are certain circumstances in which it should not be used until more information is available: pregnancy, breastfeeding, autoimmune disorders, leukemia, and lymphoma.

The dose of melatonin recommended for insomnia is 1 to 3 mg per day. However, as little as 0.3 mg per day has induced improvement in sleep in some people. Side effects from melatonin are generally not seen if less than 1 mg/day is taken, while more than 5 mg/day can exacerbate sleep disturbances.

Given the information available regarding melatonin, I mainly recommend it before someone is going on a trip that involves a change in time zone. In this case, start two to three days before leaving and take for two to three days after arriving at the new destination.

Vitamin B12. Like melatonin, vitamin B12 is useful for some people and not for others. It is thought to help reestablish a disrupted circadian rhythm and normalize levels of stress hormones. Therefore, it may be helpful for stress or anxiety related insomnia as well as short, situational insomnia from jet lag or a recent change from day to night work.

Magnesium. Some studies suggest that magnesium may be useful for insomnia related to restless leg syndrome and for reduction of the amount of anesthetic needed in the case of surgery. How these two facts translate into induction of sleep with other types of insomnia, though, is unclear.

In addition to caffeine, excessive alcohol, and particular medications, certain herbs sold over the counter can induce wakefulness. These include ginseng, ephedra, yohimbe, and cola nut. The hormonal supplement DHEA may also contribute to insomnia.

Joyce found relief from sleep disruption by adapting several of the strategies outlined in this article. First she kept a careful sleep-wake diary, which she reviewed with me and with a sleep specialist. She then instituted a regular yoga program as well as exercise three days per week around three or four in the afternoon. She cut back on caffeine and began acupuncture therapy. She also took valerian root with lemon balm and passion flower for one month until she was able to maintain a full nights sleep by acupuncture and lifestyle measures alone.