PART 2 – INTEGRATIVE TREATMENT STRATEGY FOR INSOMNIA
Natural approaches to treating insomnia are preferable for several reasons. Firstly, they will usually address the cause of the problem, rather than aim to simply alleviate the symptom; secondly they produce natural sleep, as opposed to the “coma” induced by hypnotic drugs; thirdly there are significant potential risks and side effects from the regular use of sedative drugs.
Pharmacologic agents, including over the counter (OTC) medications, such as antihistamines (such as diphenhydramine and doxylamine), benzodiazepines (such as temazepam)and novel non-benzodiazepine hypnotics (zolpidem), are recommended for no more than 4 weeks and should not be used more than 2 to 4 nights per week; long-term use increases the likelihood of both habituation and withdrawal symptoms (Attele et al. 2000; Wagner et al. 1998). Side effects include daytime drowsiness, worsened depression, ataxia, sleep walking, and addiction, nightmares or headaches. They are not to be used with alcohol.
Behavioural techniques, cognitive-behavioural therapies, and other mind/body techniques such as relaxation and biofeedback are the treatments of choice for chronic insomnia. 70% to 80% of patients with insomnia improve using non-pharmacologic approaches.
This is a deep relaxation practice with instruction by the teacher (or use of a recorded voice) in progressive release of muscle tension throughout the body in a methodical process, producing profound mental and physical relaxation. Regular practice not only relieves insomnia but creates a more fluid state of physical being.
Regular exercise, both aerobic and weight training, improves endorphin levels in the brain, promoting mental relaxation and releasing physical stress. Most people are able to do some form of regular exercise at any age. Depending upon agility and mobility exercise may range from gymnasium workouts and personal training to aquafitness (especially for those with joint problems or obesity) and simply walking, anywhere, anytime.
Sexual activity is an excellent release for many people, distracting thoughts from the day just passed, engaging intimately with one’s partner, increasing breathing rate and circulation, warming up and then cooling down after orgasm – there could not be a better formula for sleep preparation!
Massage – reflexology, aromatherapy, shiatsu, Swedish
To restore normal muscle and nervous system tone in states of stress or insomnia, what could be more logical or enjoyable than bodywork? In reflexology there are specific insomnia points on the soles of our feet. In shiatsu insomnia is thought to be caused by a congested or inflamed liver or a deficiency of chi in the heart meridian, a disturbance in the spirit due to an emotional shock or a trauma, or a generalized lack of chi in the body, all of which can be corrected with this type of massage.
The long languid strokes of Swedish massage alleviate muscle tension in general, warm the tissues and produce an endorphin effect, which causes a delightful euphoria for the recipient. A regular full body massage, paying particular attention to the back, neck and shoulders, encourages relaxation, relieves pain and tension and often breaks the cycle of insomnia.
Acupuncture and acupressure
Acupuncture and acupressure are probably the safest and most effective tools, in my clinical experience, for the immediate and lasting relief from insomnia. Clinical research clearly supports the use of these techniques to help resolve insomnia, with acupressure specifically having been studied in the elderly (Chen et al. 1999; Lin 1995).
Herbal remedies such as Valerian, Skullcap, Chamomile, Lemon balm, Hops, Passion flower and kava kava are effective for treatment of insomnia. The more sedating herbs can cause a “hangover” effect similar to hypnotic drugs, so should be dosed cautiously or prescribed by a herbalist or naturopath specifically for your purposes.
Valerian appears to improve quality of sleep and decrease sleep latency (Attele et al. 2000) and to improve delta sleep. A typical dose of valerian is anywhere from 150 to 450 mg/day of extract standardized to 0.8% of valerenic acid.
Short-term clinical studies suggest that kava kava is effective for insomnia (Attele et al. 2000; Wong et al. 1998). Kava and diazepam, in fact, induce similar EEG changes (Fugh-Berman and Cott 1999). Kava should not be used in conjunction with benzodiazepines as concurrent use with alprazolam has reportedly resulted in altered level of consciousness (Miller 1998).
Try sleeping with a hops or lavender pillow under your pillow.
Chinese herbal medicine is also extremely effective for releasing thinking processes to allow sleep to descend. The herb Zizyphus is invaluable for “calming the Shen”, or quietening the dominant mind.
Homeopathy, primarily from clinical reports, is a helpful for approach for many with insomnia. The commonest remedies prescribed are Coffea cruda and Arnica montana, but there are many constitutional remedies which may be more suitable in certain individuals (prescribed specifically by a homoeopath).
Homoeopathic melatonin may be helpful for restoring natural melatonin levels in insomniacs affected by shift work or jet lag.
Bach Flower Remedies
Bach Flower Remedies can be very simple, safe and effective solutions for insomnia. White Chestnut is excellent for “switching off persistent rattling thoughts”, while Aspen and Mimulus are beneficial where there is a fear which is affecting sleep.
Aromatherapy – particular essential oils have sedating, soothing effects on the nervous system, reducing stress-related insomnia. Try lavender, marjoram, chamomile, ylang ylang and lemon balm, 3 drops of each in a very warm bath before bed is most beneficial. The raising of core body temperature which occurs with soaking in a hot bath itself works to induce sleep in the cooling down phase afterwards.
If your insomnia is caused by being stressed or worried an affirmation repeated regularly throughout each day may improve your situation. A suggested affirmation is “I sleep soundly knowing my life is unfolding in the best possible way for me”.
- Referral to a sleep specialist is recommended if insomnia persists or if obstructive sleep apnea is suspected, to assess causes of sleep disturbances and to develop a treatment regimen.
- Regular exercise prior to dinner time; exercise too close to bedtime can stimulate arousal
- Avoid caffeine (especially after noon) and nicotine; smoking cessation may cause short-term insomnia but will diminish likelihood of long-term sleeping disturbances
- Exposure to late afternoon sun, which stimulates release of endogenous melatonin; melatonin does not induce sleep but it does help regulate the circadian rhythm
- Practice of stress reduction techniques such as yoga, meditation, or deep relaxation
Good sleep hygiene is a necessary tool for treating insomnia regardless of its cause, particularly in combination with other therapies. Practices include:
- Limiting the use of caffeine, nicotine, and alcohol
- Maintaining consistent bedtimes and wake-times, including on weekends and holidays
- Establishing the bedroom as a place for sleep and sexual activity only, not reading, watching television, working, or other activities
- Avoiding naps, particularly in the evening
- Exercising regularly, which can help regulate circadian rhythms; should be performed prior to dinner; exercising too close to bedtime may worsen insomnia
- Getting regular exposure to late afternoon, outdoor sunlight – dusk promotes production of melatonin by the pineal gland, which helps regulate normal circadian patterns
- Taking a hot bath 1 and one-half to 2 hours prior to bed; this affects core temperature and may induce sleep
- Keeping the bedroom cool, well-ventilated, quiet and dark
- Avoiding looking at the clock, especially the digital variety, which promotes anxiety and obsession about time and often unconsciously programs waking
- Avoiding drinking fluids prior to bed to avoid toilet trips during the night
- Avoiding watching television or using a computer just prior to bedtime as the screens emit bright light
Nutrition and Dietary Supplements
Maintaining normal blood sugar during the night may be helpful in preventing wakefulness. Meals rich in carbohydrates and moderate-to-low in protein and fat are assumed to promote serotonin and melatonin synthesis, and thereby to promote sleep. Try a protein supper just before bed, especially if you have had an early dinner, such as a handful of almonds, a fruit and yoghurt/tofu dessert or a boiled egg on a crispbread.
L-tryptophan and 5-hydroxytryptophan (5-HTP)
L-tryptophan is thought to function by raising serotonin levels, which in turn induces sleep (Attele et al. 2000; Cauffield and Forbes 1999). According to the Royal Pharmaceutical Society of Great Britain pharmacopeia, 1 g of L-tryptophan can decrease sleep latency by enhancing subjective sensations of sleepiness and by reducing waking time (Attele et al. 2000).
Caution is advised in prescribing L-tryptophan due to the possibility of adverse reactions leading to “serotonin syndrome” when used concomitantly with monoamine oxidase inhibitors and selective serotonin reuptake inhibitors (SSRI).
Melatonin appears to be most useful for inducing sleep in particular people, such as those with disrupted circadian rhythm (e.g., jet lag, night shift work, poor vision) (Skene et al. 1999; Wagner 1999) and in persons with schizophrenia who tend to have low levels of melatonin (Shamir et al. 2000).
Generally, 1 to 3 mg of melatonin is recommended for sleep; but as little as 0.3 mg has been used successfully.
- Night shift workers are at higher risk for motor vehicle accidents; 53% of night workers fall asleep on the job at least 1 night per week.
- Elderly patients need special attention when being treated for insomnia. Pain medication, for example, needs to be adequate to permit good sleep. However, avoiding oversedation is important. This population is more susceptible to side effects of medications and suffer from falls as well as car accidents. Medications are frequently overprescribed in nursing homes.
- Alcohol should be avoided with prescription or OTC hypnotics. In fact alcohol is not a safe remedy for insomnia due to its addictive potential and risk of side effects of regular and long term use, especially social problems.
- Rapid withdrawal of OTC or prescription sedatives can lead to rebound insomnia.
- Benzodiazepines can cause oversedation, particularly if used for substance abuse or sleep apnea patients.
- Insomnia usually occurs in the later months of pregnancy when the mother’s size and need to urinate disrupt sleep
- Benzodiazepines should be avoided during pregnancy and lactation; use during first trimester may increase risk of development of cleft lip in newborn.
Write a list – if you worry and find you have thoughts rattling around inside your head while you are trying to get to sleep, try writing them down in a journal. It may be your “to do list” for tomorrow or it might be a creative downloading process. You can also tell your troubles to a “trouble doll” that the Guatemalan Indians favour, to mind their worries overnight until they can be addressed after waking.
Create a restful environment in your bedroom – no TV or computer, soft lighting (preferably the golden glow of candlelight), soft colours for your furnishings, light ventilation, fresh comfortable bedding and clothing (if you wear any) and silence or soothing music.
Have a warm drink – a warm spicy chai with honey, a chamomile tea, or a herbal tea blend for insomnia from your herbal teahouse.
Have a light supper if you tend to wake hungry during the night, or you have had dinner several hours earlier.
Say an affirmation – “All is well in my world” , “I enjoy deep and replenishing sleep tonight and every night”.