Dr. Chuck Wile is a supervising physician at Cheng Integrative Health Center/Doctor’s Weight Loss Center, Columbia, SC. Dr. Wile served in the US Air Force Medical corp and is a retired Air Force Colonel.
It is exhausting and frustrating when you have difficulty falling asleep or staying asleep. Sleep deprivation is not the same as insomnia. In sleep deprivation one has an adequate ability to fall asleep yet an inadequate opportunity to sleep. In insomnia, one has an adequate opportunity to sleep yet an inadequate ability to sleep with sufficient quantity and/or quality of sleep. Insomnia is defined as an inability to have adequate sleep 3 or more times per week for 3 months, without co-existing mental nor physical disorder that causes sleep impairment resulting in dissatisfaction with the quality and/or quantity of sleep AND daytime impairment or distress. 1/9 Americans meet these criteria with equates to over 40 million people. Women are twice as likely as men to suffer with insomnia. African Americans and Hispanic people experience insomnia more than Caucasians. About 2/3 people experience sleep impairment 1 night/week. There is an hereditary aspect to the problem 28 to 45 percent of the time (depending on the study). >$30 Billion per year is spent on medications for sleep in the USA.
Our sleep-deprivation is caused by many socially engineered factors. Too much light, especially blue wavelength light from LEDs; use of alarm clocks because we have to punch time cards for work; room temperatures too high; the use of caffeine, tobacco and alcohol. Also, internal factors such as aging and worrying have a significant influence. Our over-active sympathetic nervous system causes a release of the adrenal hormones Epinephrine and Norepinephrine that support a flight-flight-freeze response to threats to our survival {both real and imagined}, which increases our heart rate and blood pressure and keeps us alert). Also, with the release of Cortisol from the adrenals (which supports our ability to sustain stress) there is an additional stimulus to remain alert. These hormones also cause an increased metabolic rate with consequent increased core body temperature; stimulation of the thalamus gate-keeper to remain open for sensory input for processing by the cerebral cortex,; and, for the emotion generating area of the limbic system (the amygdala) plus the memory recollection center (the hippocampus) to remain active. The result is ALERTNESS thwarting sleep. PLUS, our sleep-procrastination is a problem. Due to our fears of missing out we amuse ourselves with late-evening TV and digital entertainments which can interfere with achieving a good sleep pattern.
A Key Principal for managing insomnia is find the cause then treat the cause.
CAUSES OF INSOMNIA: 1) Acute Insomnia: Transient and short-term cause of insomnia include: jet lag; shift work; high altitude; poor sleep environment: uncomfortable room temperature—too hot or too cold; excessive or unpleasant noise; situational stresses: illness or death of a loved one, unemployment, separation or divorce, exam prep; acute medical/surgical illness or hospitalization; use of stimulants such as caffeine, amphetamines, tobacco, cocaine, MDMA, methylphenidate, modafinil, and phentermine; withdrawal from alcohol, sedatives, stimulants; and, excessive mental or physical stimulation in the hours before bedtime. 2) Chronic Insomnia: is typically linked to psychiatric or medical conditions including: a) Common Psychiatric Conditions: anxiety with intruding ruminations, depression (which can also trigger hypersomnolence), mania (bipolar disorder), PTSD and schizophrenia. b) Chronic Medical Conditions: pain, obstructive sleep apnea, restless leg syndrome and periodic leg movements, menopause or andropause, coronary artery disease with nocturnal dyspnea or angina, GERD, degenerative neurological disorders such as Parkinson’s disease and Alzheimer’s disease with dementia with nocturnal agitation, brain tumors, strokes, brain trauma, circadian rhythm disorder, medications such as stimulants for ADHD and narcolepsy, alcohol and drug users, nocturnal asthma and pregnancy.
***A thorough history and physical examination with diagnostic testing, especially considering a sleep lab study, is very important in order to make an appropriate diagnosis and precision treatment recommendations. Suggestions about supplements and medicinal essences are intended for educational purposes and are not prescriptions for managing your health concerns. Be sure to inform your physician of any supplements that you are taking in order to evaluate any possible conflicts with prescription medications.
DEVELOP STRICT SLEEP HYGIENE HABITS:
Here are some suggestions to try before considering a prescription medication. AVOID CAFFEINE (coffee, tea, caffeinated sodas), NICOTINE, and other Stimulants such as chocolate, Sudafed or Afrin nasal spray, or, if that is too much of a challenge, then don’t use any for at least 6 hours before bedtime. AVOID HEAVY MEALS and ALCOHOL before sleep. AVOID SUGARY OR SPICY FOODS 4 to 6 hours before bedtime. However, if awakening during the night is a problem, then try eating a light snack of good fats (not carbs) before bedtime. A couple almonds, a few spoons of yogurt, a couple teaspoons of almond butter or peanut butter on a cracker can frequently do the trick. Drinking warm milk and/or eating a banana may help you get ready for bed. The amino acid tryptophan in these foods can help you to sleep.
Allow enough time for sleep. Most people need 7 to 9 hours of sleep each night. Fix a bedtime and an awakening time. Avoid napping during the day. And especially in the evening. Arrange a sleep environment that is very dark, comfortable, quiet and cool {set the thermostat for 65 degrees in the bedroom} to facilitate falling asleep quickly and staying asleep. Use comfortable bedding and keep the room well ventilated. Block out all distracting noise. Consider a white noise generator. Reserve the bed for sleep and sex. Don’t use the bed as an office, work or recreation space. Let your body learn to associate the bed with sleeping. AVOID TV in the bedroom. Don’t take your worries to bed. Worrying is a prayer for that which you don’t wish to happen. Instead, practice relaxation techniques before going to bed. Yoga, deep breathing, visualizations, progressive muscle relaxation can all help relieve anxiety and muscle tension. Establish a pre-sleep ritual such as a warm bath (especially using Epsom salts—5 cups: the magnesium will relax your muscles), or a few minutes of reading or praying. Get into your favorite sleeping position. If you don’t fall asleep within 15-30 minutes, get up and go into another room and read until you get sleepy. Consider elevating the foot of your bed a few inches to increase circulation to your brain. Regular AEROBIC EXERCISE is the best way to improve your sleep and modify pain. However, don’t do heavy exercise within 3 hours before bedtime because it raises your core body temperature and it takes several hours to return your core body temperature to normal. The best time for aerobic exercising is in the morning.
COGNITIVE-BEHAVORAL THERAPY (CBT): is the most effective psychological intervention to help with insomnia. It consists of a comprehensive program for educating and modifying behaviors. The most effective use of CBT combines several of these methods. Rather than just relieving symptoms, it addresses the underlying cause(s) of insomnia. 1) Sleep Education: understanding the sleep cycles and learning how beliefs, behaviors and outside factors affect sleep. 2) Cognitive Control and Psychotherapy: helps control or eliminate negative thoughts and worries that keep one awake. It may help to eliminate worrisome beliefs about sleep such as a single restless night will make one sick. 3) Sleep Restriction: limiting the amount of time spent in bed rather than lying in bed awake which can become a habit leading to poor sleep. 4) Remaining Passively Awake: avoiding any effort to fall asleep. Worrying that one can’t sleep can keep one awake. 5) Stimulus Control Therapy: helps remove factors that condition the mind to resist sleep. Eg. One is coached to use the bed only for sleep and sex; and, to leave the bedroom if unable to sleep within 15 minutes. 6) Sleep Hygiene: changing basic lifestyle habits that can influence sleep: eg. Smoking or drinking caffeine late in the day; drinking a “nightcap” of alcohol; not regularly exercising; avoid napping; winding-down 2 hours before sleep time. 7) Relaxation Training: learning to calm the mind and body: eg. meditation, progressive muscle relaxation and hypnosis. 8) Biofeedback Training: learning to influence heart rate, skin temperature, muscle tension and skin electrical conduction. 9) Sleep Diary: keeping a detailed record of sleep patterns and influences for 2 weeks.
***This handout is intended for sharing information. If you consider trying any non-prescription supplements, please discuss this with me so that we can be sure that there will be no drug-supplement adverse interactions, and to be sure that your choice may be good for your overall care and health.
NON-PRESCRIPTION ALTERNATIVES:
These products will support and enhance normal sleep mechanisms. Consider using: 1) VALERIAN ROOT capsules– 150 to 300 mg of a standard extract (0.8% valeric acid). Use 1 capsule at bedtime. Note: it smells like dirty gym socks, however, it is an ingredient in many proprietary sleep aids because it is effective. Don’t take with alcohol. 2) MELATONIN–this comes as capsules, drops and lozenges. Women should start at 1 mg to 3 mg at bedtime and increase the dose every 4-7 days to 3 to 10 mg (may use up to 30 mg); Men should start at 3 mg to 5 mg and increase the dose every 4-7 days to 10 to 15 mg (may use up to 30 mg). 3) LAVENDER ESSENTIAL OIL (to be used topically)–add to a warm bath before bedtime or use as aromatherapy by placing some drops in an air infuser or sprinkled on bed clothes/bedding. 4) The following TEAS (which can also be used as tinctures) have been found to be helpful: a) lemon balm, b) passion flower, c) chamomile, d) catnip, e) hops, and/or rooibos. 5) Consider 5-hydroxy-tryptophan (5-HTP) 50 to 200 mg at bedtime. (CAUTION: Don’t use this if taking an anti-depressant.) 6) Consider GLYCINE 3 gm at bedtime. People fall asleep quicker, drop into delta-wave sleep faster, and report increased alertness with less daytime drowsiness, improved memory performance and less fatigue. 7) Consider using an aqueous extract derived from peeled rhizomes and roots of a non-mouldy Noble KAVA cultivar, limiting use to 250 mg kavalactones daily for acute or intermittent use. This will minimize a very rare hepatotoxicity risk. It is wise to limit its use to 6 weeks at a time and discontinue its use if there is persistent nausea, jaundice or weight loss. Then, get liver enzyme testing if there are any adverse findings. Used wisely, kava is a safe and effective aid for good sleep and to relieve moderate anxiety. 8) ZIZYPHUS seed (Suan Zao Ren; red date; the spiny jujube) is a Chinese herb beneficial for sleep, menopausal symptoms and anxiety. The dose is about 4.5 gm of the dry seed extract. 9) Magnesium L-Threonate 1,000 to 2,000 mg taken at bedtime can be very helpful with sleep management. This form of magnesium most easily crosses the blood-brain barrier with comprehensive benefits for sleep, anxiety and cognitive function. {It can be obtained from www.LifeExtension.com.} However, magnesium oxide 400-800 mg, magnesium glycinate 400-500 mg, and magnesium asporatate 400-500 mg can also be very effective. 10) SAMe (s-adenosylmethionine) 800 to 1600 mg daily can benefit insomnia. It promotes the function of the enzyme that converts N-acetylserotonin to melatonin. 11) A proprietary blend called “SleepCycle” from www.puretango.com has Xylaria Nigripes or “Wulinshen” as a main ingredient. It is a fungus containing GABA which improves sleep, shortening the time to fall asleep while helping to stay asleep longer, awakening refreshed without bothersome side effects. In fact, it has the pleasant side effect of improving cognitive function and a sense of well-being. Wulinshen also seems to have a cumulative effect, improving sleep quality with continued use. Additionally, melatonin, 5-HTP, L-Theanine plus a blend of valerian, passion flower, lemon balm, Dong quai, Hops, polygala and Jujube are added to the mixture for additional sleep benefits. The recommended dose is 2 capsules 30 minutes before bedtime. 12) Lactium is a protein hydrosolate that can be used to relieve stress and promote restful sleep without side effects. Drinking warm milk has often been suggested for promoting sleep. Unfortunately, adults no longer have the enzymes of a newborn child which allows the release of this relaxing milk peptide. Lactium 150 mg taken 1 hour before bedtime improves sleep quality and reduces the time for sleep onset after 2 weeks of use. There is no awakening-sedation nor addiction with continued use. Additionally, bioactive milk peptides activate brain cell receptors for neurotransmitters that reduce anxiety, such as GABA, serotonin and dopamine. Unlike benzodiazepine drugs, which activate the same receptors but which can become habit forming, bioactive milk peptides induce relaxation and sleep without the disinhibition side effects that are associated with risk taking behavior with such drugs. Studies demonstrate supplementing with bioactive milk products compared with placebo additionally improved digestion, cardiovascular function, cognitive function and social difficulty and reduced the stress response, including elevated blood pressure, heart rate ad cortisol levels. {Eur J Nutr. 2005;44(2):128-32.} 13) If your main problem is an active mind ruminating about things that happened during the day or things that need to happen in the future, then consider using the amino acid L-Theanine 200 mg: take 1 or 2 tabs once or twice per day. 14) Passion Flower rebalances signals in the endocannabinoid system that acts like a dimmer switch to tone down the amount of neurotransmitters that get released. It is useful to help you fall asleep and to stay asleep and to restore your sense of a calm focus. It is safe to use with children. It has been found to be useful helping to calm kids with Autism and with ADHD. A good proprietary product is called “Neural Balance” and is available from www.neural-balance.com. 15) “PharmaGABA” is a proprietary product that modifies the natural neurotransmitter gamma-amino-butyric acid (GABA) in a fermentation process with the bacteria Lactobacillus hilgardii. It can help to improve sleep quality and decrease awakenings. Additionally, it can help to relieve anxiety. The dose is 50 mg up to 200 mg daily.
OVER-THE-COUNTER MEDICATIONS:
Antihistamines are used for the side-effect of drowsiness. {Histamine is a key neurotransmitter for alertness.} Typically they contain Diphenhydramine (Benadryl, Sominex, Sleep-Eez, Nytol) or Doxylamine (Unisom). Prescription Hydroxyzine (Atarax or Vistaril) may also be used. Side-effects include: daytime drowsiness, cognitive impairment, dizziness, drunken movements, urinary hesitancy, blurred vision, dry mouth and dry throat. Caution should be exercised in people with glaucoma, benign prostatic hypertrophy and cardiac dysrhythmias. BE AWARE: studies show in people >60 yo who use anti-histamines regularly have impaired memory and an increased risk for developing dementia!!
PRESCRIPTION ALTERNATIVES:
Caution: People who are recovering from alcoholism should AVOID using benzodiazepines, Zalepion (Sonata), Zolpidem (Ambien) and Eszopiclone (Lunesta) for insomnia because there is strong evidence of relapse associated with their use. Trazodone up to 100 mg at bedtime is the preferred medication for recovering alcoholics and people with an addiction history.
“Sleeping Pills” are a misnomer. There is a significant difference between natural sleep and drug-induced SEDATION. Sedation does NOT equal sleep. Sedatives anesthetize the cerebral cortex but do NOT produce the electrical activity that is associated with sleep nor any of the restorative benefits! They produce an imbalance in the chemicals which signal the brain to achieves normal sleep, and they significantly limit restorative NREM slow-wave sleep. Also, the unconscious “limbo state” produced can result in abnormal sleep behaviors which range from the harmless and humorous to the disturbing and dangerous.
Currently there are no prescription medications used for sleep that enhance health and longevity. They all have serious potential side-effects. Thus, I believe that the risks do NOT outweigh the benefits of their use which, when compared to using a placebo, only minimally shortening the time for falling asleep. Compare this to the real risks of DEATH and CANCERS. The risk of death increases with the quantity used. For example in a 2 ½ year long study: ½ to 18 pills/year increased the risk by 3.6 times and >132 pills/year increased the risk 5.3 times. The risk of death occurs because of increased infections {since there is no immune benefit which is gained with natural sleep}; increased fatal car crashes; increased falls and consequent hip fractures {especially in the elderly}; and, increased heart disease and strokes. Especially worrisome is the fact that >50% of all sleeping pill prescriptions are for the elderly.
In addition to the above non-pharmacological suggestions, I may be willing to prescribe A SHORT COURSE of medication for people who suffer from chronic insomnia. REMEMBER: the first-line therapy is CBT-I. Medications are intended only for short-term use (7 to 10 days) and really should never exceed 4 weeks. Unfortunately, they are being used off-label for extended periods of time.
Weighing the risks versus benefits is fundamental. ALL of the sedative-hypnotics carry the risks of dependency, withdrawal and rebound insomnia. These include both the benzodiazepines and non-benzodiazepine hypnotics, although the older medications such as benzodiazepines carry a higher risk. Anti-depressants can also be used for their side-effect of drowsiness.
- Benzodiazepines: non-selectively target receptor sites in the brain that modulate the effects of the neurotransmitter gamma-aminobutyric acid (GABA). There are 3 categories: a) Long-acting: common brands include: Clonazepam (Klonopin), Diazepam (Valium), Flurazepam (half-life 70-90 hours) and Quazepam (Doral). b) Medium-acting: common brands include: Triazolam (Halcion), Lorazepam (Ativan) and Temazepam (Restoril). c) Short-acting: common brands include: Alprazolam (Xanax) and Oxazepam. These may be useful for air-travelers who want to reduce the effects of jet lag. Side-effects for all the benzodiazepines include allergic reactions, including angioedema of the face; increased depression; respiratory depression; residual daytime drowsiness with risks of motor vehicle accidents and falls in the elderly; memory loss—sleep walking, sleep eating, odd mood states: significantly aggravated by drinking alcohol and using antihistamines; and, urinary incontinence, especially in the elderly. NOTE: I am concerned about some recent studies that show a strong association between using benzodiazepines and significantly increased risks for dementia. When used for 3 to 6 months, the risk of developing Alzheimer’s disease is increased by 32%. When used for more than 6 months, the risk increases to 84%. Also, these drugs cross the placenta and enter breast milk and should be avoided in pregnancy and with nursing. First trimester use is associated with cleft lip in newborns. Interactions: although relatively safe if taken alone in an overdose, benzodiazepines are potentially very dangerous for respiratory depression in combination with drinking alcohol. Prolonged use creates physical dependence making discontinuation very problematic. Withdrawal symptoms: can last for 1 to 3 weeks after stopping the drug and include gastrointestinal distress, sweating, cardiac dysrhythmias, and, in severe cases, hallucinations and seizures. Rebound insomnia: paradoxically, benzodiazepines can cause nocturnal sleep disturbance and anxiety. There is a higher incidence of these problems especially when using the short-acting drugs.
- Non-Benzodiazepine hypnotics: although they have been advertised as causing less physical dependency than benzodiazepines, they are still subject to abuse. a) Ambien: typically induces sedation for 7 to 8 hours. AMBIEN IS A MEMORY ERASER RATHER THAN A MEMORY ENGRAVER. The FDA has recommended lowering the previous typical dose of 10 mg to 5 mg or lower, particularly for women who eliminate the drug more slowly than men. Although very popular, PLEASE NOTE: I choose NOT to prescribe Ambien because I believe that it is a dangerous drug which significantly impairs the memory and cognitive function. b) Lunesta: mayslightly improve both sleep maintenance and daytime alertness. It is the first medication approved to be taken on a long-term basis. c) Sonata: is short-acting lasting about 4 hours and useful for inducing sleep or for people with the inability to return to sleep once awakened in the middle of the night. d) Rozerem: is the only non-controlled medication. It targets melatonin receptors. However, I believe that it is an irrational choice: why not use OTC melatonin instead of the expensive prescription? e) Belsomra (suvorexant): is a new orexin-receptor antagonist being heavily advertised with a cute cuddly cat logo. “It might help you nod off a few minutes faster or stay asleep slightly longer, but that small benefit comes with some big safety concerns, such as being too drowsy to drive the next day or feeling like you can’t move or talk.” {ConsumerReports.com, July 12, 2015.} The FDA initially rejected doses of 30 to 40 mg because they posed too great a risk for causing motor vehicle crashes. The dose of 10 mg is no better than using a placebo. Compare: using Ambien 10 mg: sedated 20 min faster than a placebo and remained unconscious 34 min longer than placebo, with Belsomra 20 mg: sedated 6 min faster than placebo and remained unconscious 16 min longer than placebo. Neither are impressive nor, in my opinion, worth the risk. ***All these medications have serious side-effects: including daytime drowsiness and abnormal sleep behaviors: sleep-walking, sleep-eating, sleep-driving and social interactions with NO MEMORY for what has transpired. They impair short-term memory and can cause hallucinations and sleep paralysis. All these effects are augmented when consuming alcohol.
- Anti-Depressants: are used predominantly off-label for the side-effect of drowsiness. They are NOT addictive. They can be useful for modifying the pain threshold if pain is a confounding problem aggravating insomnia. They can be useful for concomitant depressive symptoms. They are my drug of choice for chronic insomnia. The preferred agents block serotonin 5 HT2A or 5 HT2C receptors and lack strong cholinergic activity such as: {for initial dosing} Trazodone (Desyrel) 50 mg, Doxepin (Sinequan) 25 mg and Mirtazapine (Remeron) 15 mg. Although the older tricyclic agents have a higher side-effect profile because of their strong cholinergic activity, they can also be useful, such as Amitriptyline (Elavil), Nortriptaline (Pamelor), Imipramine (Tofranil) and Desipramine (Norpramin). However, I am not cavalier about using the anti-depressants because they change the architecture and function of the brain. {READ: “Anatomy of an Epidemic” by Robert Whitaker, published in 2010.}
***Also, consider reading “The Sleep Revolution” by Arianna Huffington. AND, “Why We Sleep” by Matthew Walker, PhD.
***THE GLYMPHATIC SYSTEM: The more waste products lying around the brain, the greater the chance for Alzheimer’s disease to take root. Since 25% of the body’s overall energy is consumed by the brain, there are a lot of waste products to be cleaned up. The glymphatic system is the brain’s clean up system. Specialized brain cells scavenge diseased and damaged bits of protein and metabolic waste. With age, these cells become impaired. Also, the neuron surrounding supportive glial cells shrink in size when sleeping, opening spaces between cells by as much as 60% which allows cerebral spinal fluid to be pumped through and clear out waste. Lymphatic vessels surrounding the brain then deliver the waste to the lymphatic system of the body which gets rid of the toxins. With aging, adults often struggle to get enough sleep, which impairs the clean up system. THUS, since sleeping is crucial to removing toxins, keeping a regular sleep schedule becomes increasingly important with aging. Irregular sleep hours and long day time naps can disturb an effective sleep cycle clean up process. Also, sleeping on your side, in a fetal position, rather than on your back or stomach, does a better job of cleaning house. And, sleeping on your left side maximizes your body’s circulation, because most venous return travels up your right side and these veins can be compressed when you lie on them. However, getting good sleep is much more important than worrying about whether or not you sleep on your side and what side you sleep on.
REF. Dr. Elsie Taveras “Lack of Sleep linked to behavioral problems I kids”, March 2017, Reuters.com. “ Children who aren’t getting the recommended amount of sleep (>11 hours) have more difficulties with attention, with emotional control, wit reasoning, with problem solving, and also have behavioral problems.” …”The more chaotic and less predictable a sleep schedule, the more difficulty kids tend to have with sleep.” Consequences of sleep deprivation include: problems in school due to poor concentration, falling asleep in classes, problems with teachers; behavioral issues due to poor impulse control and bullying; mental disorders such as ADHD and depression; and, negativity and stubbornness resulting in a poor attitude and poor cooperation, isolation, poor performance, and poor social skills. While adults get lethargic with a lack of sleep, kids speed-up, become emotionally weak and violent, and have mood swings. They are unable to understand what is wrong with them.
SUGGESTIONS:
- Maintain a regular bedtime and getting-up time, including weekends and holidays, if possible.
- Create a winding-down time in the evening, and a relaxed bedtime ritual—eg. reading or telling stories together, and tucking-in for the night with a lullaby.
- Avoid caffeine, colas, and chocolate at night.
- Avoid heavy meals and sweets at night.
- Keep the bedroom a comfortable temperature (around 65 degrees), with darkness and quiet.
- Avoid all screens and music.
- Exercise for at least 60-minutes daily, but not within 2 hours of bedtime.