“To sleep: perchance to dream…” 1
Sleep is something so many take for granted and yet insomnia affects a large proportion of the population, 22.1% by recent estimates 2. Untreated insomnia can lead to psychiatric disorders such as anxiety and depression and insomnia commonly occurs in those with psychiatric disorders. Treating the underlying psychiatric disorder will generally improve sleep.3 In the long nights at this time of year, those suffering from insomnia often suffer even more. So to offer some solace in the dark, winter nights, let me explain a little about some of the causative and contributing factors to sleeplessness and some tips that will hopefully improve your slumber.
Insomnia can be caused by a number of factors- ranging from organic (caused by physical health conditions such as pain, headaches, GERD (gastroesophageal reflux disease), hyperthyroidism and hot flashes) to nonorganic causes (not caused by physical health complaints, but may be caused by other factors such as: substances (drugs, caffeine, alcohol and some herbs used to improve adrenal function such as Maca), an underlying mental health disorder, stress, environmental disruptions (bright light at night, uncomfortable temperature in the room) and stress.
In insomnia it is important to rule out physical causes to ensure good physical health and appropriate treatment for insomnia. Once physical causes have been ruled out, a comprehensive evaluation of nonorganic causes is necessary to accurately address the causative and contributing factors to nonorganic insomnia.
A number of medications can contribute to insomnia. These include (but are not limited to): SSRIs, stimulants (such as Ritalin), anticonvulsants, thyroid hormones, steroids (prednisone and others), heart and blood pressure medications and decongestants.
Lifestyle factors that can affect sleep include shift-work, exercising late at night, eating dinner late (especially when it is a heavy or rich meal), nicotine or alcohol up to 6 hours prior to bed, bright ambient light, cool temperatures in the evening and lest we forget a noisy environment due to noise outside one’s bedroom…or within it with a snoring partner!
Helpful tools that one can use to do a bit of evaluation on your own include4:
-The Epworth Sleepiness Scale to assess the impact of insomnia on your life (available at: http://yoursleep.aasmnet.org/SleepScale.asp) or for adolescents, the
-A Sleep Diary –a useful tool to track the impact of a variety of factors on your sleep. I encourage people to add in a symbol for when they eat (as meal times can affect sleep) and an asterisk for days in which a note about the stress-level of the day or some other is notable factor seems warranted. These notes can be made on a separate page). For a sample` of a sleep diary, see: http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf.. Check back on my site soon- in the ‘Patient Forms’ section for an elaborated version of the Sleep Diary.
- A Sleep Evaluation- to assess your need to get further medical help – available at: http://yoursleep.aasmnet.org/SleepEval.aspx
And finally, some tips you can try on your own:
- Sleep Hygiene- reserve the bedroom for sleep and sex. Do not watch TV, read, study or eat in bed. Consider before bed rituals such as a warm bath, meditation, listening to relaxing music, reading a good book (but not too good or stimulating!)….and if you can’t fall asleep after giving it a good try (20-30 minutes), get out of bed, stay warm, use only dim light and don’t eat or drink much unless hunger has been keeping you from sleeping. Limit caffeine, alcohol and nicotine intake for up to 6 hours before sleeping. And establish regular sleep and wake times that are consistent each night.
- Chronotherapy- (Includes some of the suggestions above) and limiting screen exposure at night, wearing amber glasses once it is dark outside, a regular sleep-wake schedule, sleep in a dark bedroom and get morning light
- Hydrotherapy- warm (not hot) salt baths prior to bed. Warm baths warm the core and this signals the body to relax and to sleep. Adding aromatherapy (lavender oil is usually a good one to try) can be helpful too.
- Herbal/Supplemental/Nutritional- a note on Valerian: while this herb can help many with sleep problems, in a small portion of the population, it can have a paradoxical stimulating effect. As with all herbs, herbs for sleep (of which there are many) need to be used wisely to avoid drug interactions and to improve efficacy. There is validity to the warm milk home remedy. Warmed milk or milk alternative (often with a little nutmeg added) is a widely used remedy in Ayurveda to aid sleep. Eating more simply at night, eating lightly cooked foods and including some carbohydrates in your evening meal can often aid sleep. There are also a number of vitamins and minerals that can be of help. Melatonin is often more helpful in establishing and maintaining a regular sleep-wake rhythm than in inducing sleep per se.
And a note of caution, while sleep medicines may be necessary acutely when insomnia is severely impacting one’s daily functioning and safety, they do not cure insomnia, are associated with a number of side effects 5 and can adversely affect the quality of one’s sleep and suppress or affect normal dreaming6 (which is important for consolidation of memory and to promote psychological awareness and healing).
We spend a third to a half of our life sleeping and there is so much more to be said about sleep. I will be covering it in more depth in future postings and classes. I hope that you have found this post to be helpful. If you suffer from insomnia, please be sure to seek help- it is critical to your mental-emotional and physical health to get good quality rest on a consistent basis.
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1 Thompson, A. & Taylor, N., (Eds.). (2006). Hamlet. (3rd ed.). London: Arden Shakespeare, 63-64.
2 Roth, T., Coulouvrat, C., Hajak, G., et al. (2011). Prevalence and perceived health associated with insomnia based on DSM-IV-TR; International Statistical Classification of Diseases and Related Health Problems, Tenth Revision; and Research Diagnostic Criteria/International Classification of Sleep Disorders, Second Edition criteria: results from the America Insomnia Survey. Biol Psychiatr, 69(6), 592-600.
3 The Cleveland Clinic Foundation (2010) . Health Information. Diseases and Conditions: Sleep and Psychiatric Disorders. Retrieved from http://my.clevelandclinic.org/disorders/sleep_disorders/hic_sleep_and_psychiatric_disorders.aspx
4 American Academy of Sleep Medicine. (2010). Evaluate Your Sleep. Retrieved from http://yoursleep.aasmnet.org/evaluatesleep.aspx
5 US Dept. of Health & Human Services. (2012. Mar. 14)*. Consumer Updates- Side Effects of Sleep Drugs. Retrieved from http://www.fda.gov/forconsumers/consumerupdates/ucm107757.htm
6 Pagel, J.F. & Parnes, B.L. (2001). Medications for the Treatment of Sleep Disorders: An Overview. Primary Care Companion J Clin Psychiatry, 3, 118-125. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181172/pdf/i1523-5998-003-03-0118.pdf
*Post updated with this information after initial posting date