Insomnia and Its Implications

Paul L. Reller L.Ac. / Last Updated: August 03, 2017


Behavioral and cognitive changes are important in a holistic protocol to cure insomnia and correct the underlying causes, as are environmental changes

Many studies are now being conducted to see if the protocols of sleep clinics have a measurable effect on chronic insomnia. Cognitive habits and established routines, changes in the sleep environment, avoidance of eating and digestive activity before bedtime, and mild increases in aerobic activity are found to be important in the treatment protocol. For instance, a 2011 study at the Universidade Federal de Sao Paolo, Brazil, of patients with primary chronic insomnia found that moderate aerobic excercise, performed either in the morning or late afternoon, demonstrated significant benefits to sleep as measured with polysomnography, and subjective measures of anxiety, depression, and total mood disturbances improved as well (see study link below). Similar study showed significant benefits compared to use of sleep hygiene education alone at Northwestern University in Chicago, Illinois. The effects may not be immediately apparent with aerobic exercise in all cases, and these studies provided for 4-6 months of a mild routine to achieve success. Other forms of activity, such as Tai Chi (Tai Ji), a traditional Chinese public health exercise in the realm of Qi Gong, have also been studied and found to be effective. A 2004 study at the Oregon Research Institute in Eugene, Oregon, enrolled 118 patients, aged 60-92, in 24 weeks of Tai Chi sessions, and found significant benefits in treating insomnia as measured by the Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale, as well as mental and physcial fitness tests. Qi Gong routines in China have provided the population with mild exercise routines that also involve focused breathing and stress reduction for centuries. These simple routines may be taught and learned, performed at home with just 10 to 20 minutes per day of activity, and contribute greatly to the success of the insomnia treatment protocol.

You may wonder what exactly sleep hygiene is. The word hygiene means the science of health and its maintenance, as well as the more familiar cleanliness that promotes health. Mental hygiene is the key issue in the protocols for improving sleep quality, but a healthy daily routine with behavioral, cognitive, and environmental changes are what the experts are talking about with the term sleep hygiene.

This type of public health education and attention to the mind-body aspects of medicine have been integral to the practice of Traditional Chinese Medicine for many centuries, with China historically being the first country to adopt widely the promotion of healthy habits and exercises to decrease the burden of healthcare on the state. With the insomnia protocols, research supports the same type of advice we see in TCM, namely the adoption of better routines and habits, control of the environment in the home and workplace, and the adoption of simple relaxation routines before bedtime. This type of holistic protocol was addressed in the foundations of TCM literature, and is seen in various TCM texts dating as far back as 300 BC. The International Classification of Sleep Disorders states: 'The importance of assessing the contribution of inadequate sleep hygiene in maintaining a preexisting sleep disturbance cannot be overemphasized."

Set routines help your mind and body establish a better diurnal pattern, and take physiological and psychological stress off of the patient. By establishing a set time to turn off the television or computer, adopt a relaxation routine, and then perhaps read a relaxing book as you get sleepy, you will train your mind and body to easily improve its diurnal regulation of biochemical changes. Controlling the environment in the bedroom may be especially important. While it is tempting to use the bedroom to watch television or work on the laptop, this has been shown to be deleterious to sleep habits. Use the bed for sleep and sex, not work and entertainment. This type of conditioning will program your mind to adopt the bedroom as a trigger to achieve the biochemical changes needed to fall asleep and sleep soundly. Make sure the bed is not facing the door or a window if possible, and that temperature changes during the night are controlled. In traditional China, this is called Feng Shui, or the Daoist science of creating the healthiest environment for the mind and body. The term Feng Shui incorporates the words for Wind (flux) and Water (movement), and while this term is made superficial in concept today, it has traditionally been viewed as a very important concept in China, affecting the government, business, home and health, by promoting a sense of controlled movement and flux in the environment, which could be called the qi of the environment. A well designed bedroom may place the bed in a position that is not disturbed by the outside world, enjoys the right light in the morning, creates a soothing dimming of light before sleep, and has soothing colors and fresh air. During the day, the air is refreshed with an open window, but at night all drafts are avoided, and the temperature in the room is kept at a cool and even range. The body temperature drops during deep sleep cycles, as the circulation is directed from the peripheral tissues to the organs, especially the liver. Helping the body to achieve this temperature regulation smoothly is important.

Habits before bedtime that may improve sleep include warming the palms and soles by rubbing them together and deep breathing. Use of a heating pad to increase circulation to tissues that are painful may be helpful. A gentle massage from a partner may encourage deeper sleep as well. A few minutes of a deep breathing routine may be helpful, with slow diaphragmatic breathing achieved, a method of lowering high blood pressure proven to work at the Mayo Clinic. In this exercise, the breathing in slowly from the nose, first expanding the abdomen below the diaphragm and then the full chest expansion, pausing, and then slowly letting the breath out through the mouth, trying to count 3 to 6 seconds of outbreath, will help the body coordinate its physiological activity. Avoiding shallow breaths and puffing, or blowing the air out during the exhalation, is important, as a relaxing slow sigh and release of the breath is a reflex to relax the muscles of the chest, diaphragm, and lung. Deep diaphragmatic breathing exercise often requires some practice, and is not comfortable for many on the first try. Creating a soothing smell in the bedroom in helpful for many as well. The use of essential oils, such as amber, the mild scent of frankincense, either as a smoke or with the essential oil, is often very helpful. Other scents may also be soothing, and the patient can explore these by going to a shop that has high quality essential oils and incense and experimenting. For patients with cardiopulmonary pathology or nighttime congestion, some essential oil scents can be very helpful to maintain a more open airway. A study in 2008 at Semmelweiss University, in Budapest, Hungary, showed in a randomized human trial that listening to relaxing music at bedtime improved sleep quality significantly, and showed a decrease overall in depressive symptoms. All or any of these sleep hygiene habits can be individualized into a simple and short bedtime protocol that fits each individual's needs.

Proper resetting of the circadian rhythms has been found to be particularly helpful to many patients. Sunlight helps the body reset its internal clock each day, and sleep hygienists recommend that waking to the sunrise, if possible, and exposure to bright sunlight first thing in the morning for up to an hour, has been proven to be helpful in resetting circadian rhythms and falling asleep easily the next night. Over time, resetting circadian rhythms may help with the diurnal regulation of cortisol and other important hormones that exert effects on our neurotransmitters and neurohormonal receptors. Adopting a routine of yoga or a brisk walk in the sun, first thing in the morning, may provide a healthy and effective way to reset the body's internal clock and circadian rhythm.

The array of techniques and advice in the realm of sleep hygiene can be complex, or the advice may be simple. The University of Maryland Medical Center offers these simple tips to try: 1) set a specific sleep schedule and stick to it, and don"t wait until you fall asleep on the couch in front of the television; 2) avoid napping during the day, or limit the nap to 30 minutes or less; 3) avoid alcohol for 4-6 hours before bedtime; 4) avoid caffeine, even in soft drinks, for 4-6 hours before bedtime; 5) avoid eating heavy, spicy or sugary foods for 4-6 hours before bedtime; 6) exercise regularly, but avoid moderate to heavy exercise before bedtime; 7) keep the bedroom temperature slightly cool and steady through the night; 8) eliminate distracting noise; 9) avoid using the bed for work or recreation, eliminating the use of the television or laptop in bed; 10) if you are hungry before bed, try a very light snack, such as a banana, or other high tryptophan foods, such as pumpkin seeds, almond, taro, peanut, or a cracker with wheat, barley or oats. (A cup of peppermint chamomile tea with honey may quell the desire for a sweet snack and calm the nervous system and stomach); 11) practice deep breathing techniques or yoga before bedtime; 12) establish a pre-sleep ritual, such as a warm bath, a few minutes of reading, lighting some incense, and/or placing a drop of amber essential oil on the edge of the pillow; 13) use a specific sleeping position to induce sleepiness, and if you don't fall asleep within 15-30 minutes, don't get frustrated, just get up, go into another room, and try reading until you again feel sleepy. Keep in mind that segmented sleep, or a sleep pattern with periods of sleep divided by a period of wakefulness in the middle of the night is proven to be natural pattern for humans throughout history, not a cause of alarm, or anxiety. Experiencing a period of wakefulness in the middle of the night is not the cause of tiredness, cognitive dysfunction, or daytime anxiety. A dysfunctional sleep cycle is a problem, not a segmented sleep pattern. Work to achieve a deeper and more restful sleep, not an 8 hour continuous sleep. Experts that study insomnia find that most patients with chronic insomnia stubbornly ignore these simple human habits of sleep hygiene. By focusing more objectively on specific problems with sleep quality and underlying causes of sleep dysfunction success with restfulness will be achieved.

Stopping Medications that may cause or contribute to chronic insomnia

Patients are unaware that many medications may cause wakefulness and inhibit sleep. Individuals react differently to specific medications, and often the prescribing doctor is reluctant to address this issue, either out of concern that the patient continues with their drug therapy, or that the patient will be displeased and potentially sue. This leaves the patient to gather this information and make decisions concerning the needs for the medication and the option of discontinuing use to achieve a better sleep and rest. Of course, these issues need to be discussed with the prescribing physicians. The Mayo Clinic offers this advice: "Older people use more prescription drugs than younger people do, which increases the chance of insomnia caused by a medication." Dr. James Wellman M.D., director of the Sleep Disorders Center of Georgia in Augusta, stated in an interview that "certain heart, blood pressure, and asthma drugs, as well as over-the-counter medicines for colds, allergies, and headaches, can interrupt normal sleep patterns." Some medications that are prescribed for insomnia include warnings of adverse effects that cause insomnia. For instance, the benzodiazepine Temazepam, called Restoril, comes with these side effects listed by the National Institutes of Health on PubMed Health: hangover effect (feeling groggy the next day), drowsiness, dizziness; rebound effect when stopping the medication, with difficulty falling asleep or staying asleep, and the possibility of depression, muscle cramp, or tremor. In addition, the FDA issued drug warnings for Temazepam (Restoril) in 2009 that warned of the possibility of behavioral changes, "sleep-driving", other complex "sleep-walking" behaviors, and anaphylactoid reactions. The National Institutes of Health warns that many antidepressant medications suppress REM sleep, affecting the quality of sleep and sleep cycle rhythms.

The list of medications that could affect sleep include SSRI antidepressants, oral contraceptives, anticonvulsant medications (often prescribed for other conditions as well), attention deficit and hyperactivity disorder (ADHD) medications (Ritalin et al), decongestants, cortisone or corticosteroid medications (such as sprays, inhalers, and lotions, as well as pills), beta blockers (often prescribed for heart problems or hypertension), beta adrenergic agonists (inhalers and pills, such as asthma inhalers, heart anti-arhythmyia medications, etc.), diuretics, statin drugs to lower cholesterol, appetite suppressants and weight-reduction medications, and quinolone antibiotics. Antihistamines often make one groggy and sleepy, but can also stimulate the need to urinate at night, disturbing the sleep. Higher dosage of synthetic thyroid hormone may cause or contribute to insomnia. Some pain relieving medications contain caffeine, such as Excedrin, Anacin, and Motrin Complete, and thoughtful choice of pain medications before bedtime is important. As stated, higher dosage of some common herbal medications, such as Kava and St. John's Wort may overstimulate, and the individualized dosage is important. More rarely, some individuals respond with overstimulation when taking Sam-E or melatonin. Each individual may respond differently, and should try another type of herbal or nutrient sleep aid if one doesn't work out. Of course, a combination of these problematic pharmaceutical medications, and herbal overstimulation, increases the chance that your insomnia is related to medication side effects and makes an objective evaluation confusing. Discussing this with a Complementary and Integrative Medicine physician will help pinpoint where the problems are coming from.