Insomnia

Insomnia: Overview

Although one-third of the average person's life is spent sleeping, many of the physical and chemical bases of sleep remain a mystery.  Sleep-wake patterns are governed by circadian rhythms, which usually run on 25-hour cycles with two natural daily peak times for sleeping, at night and at mid-day, the traditional siesta time. There are three main types of insomnia based on the time of difficulty:
  1. sleep onset insomnia
  2. maintenance insomnia
  3. early a.m.  insomnia (often a symptom of underlying depression).
There is also mixed insomnia, conditioned insomnia (chronic disturbance such as a baby in the house), and dream-interruption insomnia (caused by deep anxiety).  Compulsive urination insomnia is often seen in patients suffering from fibromyalgia (FMS) due to hypersensitive nerve endings that cause wakening due to bladder pressure.

Causes and Development

Primary insomnia is not due to any other sleep disorders such as restless legs syndrome, medical conditions, drugs or mental disorders.

A large percentage of chronic insomnia cases have a serious psychological cause.  The disorders that most often cause insomnia are chronic anxiety, depression, and bipolar (manic) depression.  At least 70% of people with depression complain of insomnia.

Many common medical problems (and some of the drugs that treat them) can cause insomnia, including allergies, arthritis, heart disease, hypertension, asthma, arthritic conditions, Alzheimer's disease, Parkinson's disease, hyperthyroidism, and attention deficit hyperactivity disorder (ADHD).

Signs and Symptoms

Chronic primary insomnia is diagnosed when, for at least a month, a person has difficulty in falling asleep, maintaining sleep, or has non-restorative (ineffective) sleep, and, in addition, the patient is distressed and believes that normal functioning is impaired because of sleep loss.

Transient insomnia lasts for a few days and short-term insomnia for no more than three weeks; if sleep is disturbed for a longer period of time, a person is considered to have chronic insomnia.  It can take 4-6 weeks of getting enough sleep to fully recover from prolonged sleep deprivation.

Treatment and Prevention

Some women experience insomnia around menopause and find that hormone evaluation and balancing helps.

There are many natural treatments for insomnia that should be considered before resorting to medications.  Tryptophan, melatonin, 5-HTP, Valerian, and St.  John's Wort may help with sleep.  In difficult cases, use of these in combination have been successful.

Valerian is sometimes used as a treatment for anxiety.  However, it is more commonly recommended as an aid for occasional insomnia.  Kava is probably better for anxiety but is sometimes recommended at higher doses to treat insomnia as well.

Make sure that something you are currently taking is not causing the problem.  Substances such as panax ginseng, hydrocortisone taken late in the day, caffeine, and too much alcohol, cocaine or sedatives can cause insomnia.

Other suggestions:
  • A 1995 study showed that poor sleepers do not clear caffeine from their systems as rapidly as normal sleepers.  Even one cup of coffee at breakfast only was enough to keep them awake at night.  A two week trial of no caffeine may be beneficial.
  • Sleep in complete darkness.  A recent study indicated that even dim artificial light may disrupt sleep and melatonin production.
  • Don't nap.  Sleep disturbances may encourage napping during the day, which can make it harder to fall asleep at a normal hour.  Avoiding naps can promote sleep at an earlier hour.
  • Try taking your watch off and any clocks out of the room.  This simple technique has worked for a surprising number of people.
  • Reading for 45-60 minutes.
  • Aerobic exercise 3-5 times per week.
  • Many with FMS need a water bed, sometimes even with an egg-crate pad.  Some need a hard bed.  Find out what works for you.  Go to a store and try some.
  • If hypoglycemia is a problem, some are helped by a snack before going to bed.
  • Go to bed only when you are sleepy but get up at the same time each morning.
  • If medication is necessary, find out which works for you.  Don't give up – good sleep is worth the search.
  • Vitamin B12 can help with fatigue, insomnia, depression, and the anxiety of getting older, especially if low stomach acid is suspected.  Shots may be required for large doses.
  • Mild acting agents like homeopathic preparations, chamomile tea, a long relaxing bath, or a touch of sea salt on the tongue with a glass of water can be tried.

Insomnia

Information On This Page

Signs, symptoms & indicators of Insomnia:

Symptoms - Sleep

Risk factors for Insomnia:

Addictions

Alcohol-related Problems often increases risk of InsomniaAlcohol-related Problems
Depletion of tryptophan as a result of heavy drinking explains why alcoholics suffer from insomnia.

Allergy

Environment / Toxicity

Habits

Aerobic Exercise Need often increases risk of InsomniaAerobic Exercise Need
People often sleep more easily and soundly once an exercise program is started.

Hormones

Histadelia (Histamine High) may increase risk of InsomniaHistadelia (Histamine High)
The overarousal seen in histadelia may contribute to insomnia.

Metabolic

Tinnitus often increases risk of InsomniaTinnitus
In a double-blind study of people who had difficulty sleeping because of tinnitus, supplementation with 3mg of melatonin per night for one month resulted in improved sleep.

Nutrients

Respiratory

Insomnia suggests the following may be present:

Addictions

Insomnia may suggest Alcohol-related ProblemsAlcohol-related Problems
Depletion of tryptophan as a result of heavy drinking explains why alcoholics suffer from insomnia.

Metabolic

Insomnia may suggest TinnitusTinnitus
In a double-blind study of people who had difficulty sleeping because of tinnitus, supplementation with 3mg of melatonin per night for one month resulted in improved sleep.

Recommendations for Insomnia:

Amino Acid / Protein

Tryptophan / 5HTP is highly recommended for InsomniaTryptophan / 5HTP
Due to the fact that the synthesis of serotonin and melatonin within the brain is dependent on the availability of the amino acid tryptophan, supplementing the diet with tryptophan before going to bed may produce good results in relieving insomnia.  Tryptophan tends to work better for acute insomnia (sleep-onset insomnia) than for chronic sleep problems since its greatest effect is to shorten the time it takes to fall asleep after going to bed.

Some 1000 to 2000mg of L-tryptophan are needed in order to increase blood levels sufficiently to induce sleep.  However, the lowest dose (often as little as 500mg) that works as a sleep aid should be maintained to continue benefits.  The dose may be repeated if one wakes during the night.  Doctors often recommend starting with 1gm of L-tryptophan 30-45 minutes before bed, which will reduce the time it takes to fall asleep.  If 1000mg is insufficient, the dose may be increased by 500mg each night until either the desired effects are achieved or a total of 3000mg is reached.

Botanical

Hawthorn Berry Extract often helps with InsomniaHawthorn Berry Extract
Hawthorn tea is good for nervous tension and sleeplessness.
Valerian Root often helps with InsomniaValerian Root
Historically, the herb valerian was commonly used for the treatment of insomnia.  Although we have some studies that appear to indicate that it is effective, more research is needed to tell us how to use valerian appropriately.

Valerian is once again becoming popular in the United States; its reputation is as a gentle sleep aid without side-effects.  As one user commented, "Valerian is one of the most gentle and harmless herbal sleeping remedies I've found.  It seems to enhance my body's natural process of slipping into sleep and makes the stresses of my day recede.  I awaken relaxed and refreshed with no morning hangover."

A 28-day study of 121 people with a history of sleep disturbances compared the effect of 600mg of a valerian extract taken 1 hour before bedtime against placebo.  The study concluded that valerian is useful for the long-term treatment of insomnia.  Subjects were evaluated by a physician and by self-report at the beginning of the study and at days 14 and 28.  At 14 days, only a few significant differences were found between the two groups' outcomes, but by the end of the fourth week, the group taking valerian showed comparative improvements in quality of sleep, mood, and overall evaluation of results.  However, it should be pointed out that the results, although mathematically significant, were not dramatic.  Valerian is a very mild treatment.

A placebo-controlled study of 19 patients who complained of poor sleep, marked by reports of frequent waking, despite chronic benzodiazepine use, was conducted.  Subjects were off benzodiazepine for 2 weeks prior to beginning Valerian or placebo.  The fifteen days of treatment with Valerian improved subjective sleep quality, without affecting sleep onset.This study was of relatively short duration, 15 days.  [Prog Neuropsychopharmacol Biol Psychiatry 2002;26(3): pp.539-545]
Kava often helps with InsomniaKava
Kava Root Extract has been used by the inhabitants of the Pacific Islands for centuries as an relaxing botanical that also promotes delta-rhythm sleep.  Because it potentiates the effectiveness of melatonin, it is the ideal complement in a melatonin complex formula.  Kava (piper methysticum) has been proven to be especially effective in treating refractory sleep disorders, including those involving headaches, menstrual cramps, and gastrointestinal disorders.

Kava improves sleep by relaxing the body, reducing mental worry and anxiety, and reducing pain.  Although no scientific evidence exists that kava can help insomnia, anecdotal stories tell us that traditional healers have prescribed it for insomnia for centuries.  Kava-based products are prescribed as medicines for relaxation in France, Germany, Switzerland, and other European countries.

Although we don't have a definitive study on the effectiveness of kava as a treatment for insomnia, we can look into some studies of kava as an indication that it might be helpful in sleep.  A small double-blind placebo-controlled study suggested that synthetic kavain (a kavalactone found in kava) enhances brain activity that favors restorative sleep.  At weekly intervals, subjects randomly received placebo; 200, 400, or 600mg of kavain; or 30mg of the benzodiazepine Clobazam.  Pulse, blood pressure, EEG, psychometric tests, and side effects were noted at the outset and then at 1, 2, 4, 6, and 8 hours after receiving the medication.

EEG activity showed that kavain increased the alpha-1, theta, and delta brain waves that are associated with sleep while decreasing beta waves, which are a sign of wakefulness.  Furthermore, these effects increased with higher dosages.  At 600mg, kavain produced sedation comparable to 30mg of Clobazam. 

Unfortunately, this rather theoretical study looked at brain waves rather than true effects on sleep.  Also, it used isolated kavain rather than the whole-kava extract as you might purchase it.  Much better research needs to be performed before it can be said that scientific evidence exists for using kava in sleep disorders.

Diet

Caffeine/Coffee Avoidance is highly recommended for InsomniaCaffeine/Coffee Avoidance
People suffering from insomnia often have elevated caffeine levels compared to normal sleepers.  They may have as much as 40% of the caffeine they consumed in the morning still in their system at bedtime.  [Psychopharmacology 1995; 121: pp.494-502]

Drug

GHB (Gamma-Hydroxybutyrate) is highly recommended for InsomniaGHB (Gamma-Hydroxybutyrate)
GHB has been called "almost an ideal sleep inducing substance" [Smart Drugs II, p.  245].  Small doses produce relaxation, tranquility and drowsiness which make it extremely easy to fall asleep naturally.  Higher doses increase the drowsiness effect and decrease the time it takes to fall asleep.  A sufficiently large dose of GHB will induce sudden sleep within five to ten minutes [Laborit, 1964].

Many other hypnotics interfere with various stages of the sleep cycle thus preventing the body from achieving a complete and balanced session of rest and recuperation.  The most remarkable facet of GHB-induced sleep is its physiological resemblance to normal sleep.  For instance, GHB sleep is characterized by increased levels of carbon dioxide in the arteries, as in normal sleep [Vickers, 1969].

During both normal and GHB-induced sleep, the central nervous system continues to be responsive to "noxious stimuli" (pain and other irritations), a factor which sets limits on GHB's uses in anesthesia [Vickers, 1969].  GHB facilitates both REM (rapid eye movement) sleep, and "slow wave" (non-REM) sleep, the stage of sleep featuring increased release of growth hormone [Laborit, 1972].  And – unlike the unconsciousness induced by other anesthetics – that triggered by GHB does not feature a systemic decrease in oxygen consumption [Laborit, 1964].

The primary disadvantage of GHB's use as a sleep aid is its short term influence – some three hours.  During GHB's influence, sleep is deeper and more restful, but after the GHB has worn off, people have a tendency to wake up.  The higher the dose, the greater is this tendency.  Some have called this pattern the "dawn effect" and have speculated that it is related to the release of stored dopamine.  Some people minimize this effect by taking minimal doses of GHB.  Others take advantage of this effect by getting a couple of hours of work done in the middle of the night.  Still others choose to take a second dose of GHB to sleep for another three hours.

It should be noted that not everyone can be put to sleep by GHB.  Some people never achieve sleep even with the doses normally used for such purposes.  In addition, Takahara (1977) reported in a growth-hormone study that one man remained conscious even though he had received GHB intravenously at a dosage which rendered the rest of the participants unconscious.
Conventional Drug Avoidance often helps with InsomniaConventional Drug Avoidance
Use of benzodiazepine medications for sleep disorders has become more and more common, and is implicated in a long list of side-effects and difficult withdrawal symptoms.  Benzodiazepines are often found under the following names, Xanax (Alprazolam), Valium (Diazepam), Ativan, Alzapam (Lorazepam), Halcion (Triazolam), Klonopin (Clonazepam), and Restoril, among others.  Patients often find it very difficult to withdraw from these medications, and at the same time long-term medication with these drugs is often discouraged due to the addictive nature of the drugs and the accompanying side-effects.

Hormone

Melatonin is highly recommended for InsomniaMelatonin
The body uses the hormone melatonin as part of its normal control of the sleep-wake cycle: melatonin plays an important role in the induction of sleep.  The pineal gland – a tiny gland at the base of the brain – makes serotonin and then turns it into melatonin when light decreases.  Strong light (such as sunlight) turns off melatonin production.  Completely darkened rooms increase melatonin levels more than partially darkened rooms, and weak light doesn't completely shut down melatonin production as does strong light.

Taking melatonin as a supplement seems to stimulate sleep when the natural cycle is disturbed.  It is most dramatically effective for jet lag and for those who work night shifts and want to change their hours of sleep on the weekends.

Sustained-release melatonin may provide sleep enhancement for those who have difficulty remaining asleep.  Several double-blind trials show melatonin supplementation to be very effective in promoting sleep.  However, it appears that the sleep-promoting effects of melatonin supplementation are most apparent if an individual's melatonin levels are low.  Melatonin supplementation does not act as a simple sedative like a sleeping pill; only if this sleep-producing hormone is deficient will supplementation be helpful.  Furthermore, melatonin acts to regulate or alter sleep rhythms, so its effect may be stronger with problems getting to sleep initially than with sleep disturbances once asleep.

One week of supplementation with melatonin (0.1mg, 0.3mg or 3mg before bedtime) in 30 patients with insomnia over 50 years old with reduced melatonin levels, improved sleep in a double-blind, placebo-controlled, cross-over study.  The 3mg per day dose induced hypothermia and caused plasma melatonin to remain elevated into the daylight hours.  [ J Clin Endocrinol Metab 2001;86(10): pp.4727-4730]

One double-blind study enrolled 320 people who were given 5mg of standard melatonin, 5mg of slow-release melatonin, 0.5mg of standard melatonin, or a placebo for 4 nights following plane travel.  The results showed improvements only with 5mg of standard melatonin.  Benefits were noted in time to fall asleep, quality of sleep, and daytime drowsiness and fatigue.  Positive results were seen in several other studies but at least one study failed to find a significant sleep-inducing effect for melatonin.  On balance, the evidence is strongly positive that melatonin can help sleep.

According to one review of the literature, treatment is most effective for those with significant jet lag, such as those who have crossed more than 8 time zones.  However, melatonin also seems to be help induce sleep for other people, including those with no sleep problems to begin with.

Mineral

Magnesium often helps with InsomniaMagnesium
Because of its nerve and muscle support, magnesium may also be helpful for insomnia.

Nutrient

DMAE often helps with InsomniaDMAE
DMAE has been shown to increase daytime motivation and physical energy in persons afflicted with insomnia.  As well as reducing the amount of sleep required by about 1 hour per night, users experience sounder sleep.

Physical Medicine

Hydrotherapy often helps with InsomniaHydrotherapy
Various forms of hydrotherapy have to been used to treat insomnia.  The neutral bath tends to sedate disturbed people.
Calming / Stretching Exercises often helps with InsomniaCalming / Stretching Exercises
It is claimed that the practice of yoga will benefit your sleep in three ways:
  1. The quality of your sleep will improve because of yoga's beneficial effect on the nervous system, in particular the brain.  This results from certain yoga postures increasing the blood supply to the sleep center in the brain.
  2. You will need less sleep because of the improved quality of your sleep, and because yoga increases the elimination of toxins from the body.  On average, for every minute you put into yoga you will need one minute less sleep.
  3. You will fall asleep in a shorter time.  This is because your body and mind are more relaxed.

KEY

Weak or unproven link: may increase risk of; may suggest
Weak or unproven link:
may increase risk of; may suggest
Strong or generally accepted link: is often a sign or symptom of; often increases risk of
Strong or generally accepted link:
is often a sign or symptom of; often increases risk of
Definite or direct link: is a sign or symptom of
Definite or direct link:
is a sign or symptom of
Moderately useful: often helps with
Moderately useful:
often helps with
Very useful: is highly recommended for
Very useful:
is highly recommended for