Insomnia

Overview: Insomnia

• Insomnia is pervasive, associated with a broad range of illnesses, and presents a significant medical, social, and economic burden.

• Largely undiagnosed and untreated despite the existence of effective interventions, insomnia has been described as “unremitting, disabling, costly, pervasive, and pernicious."

• Because it is strongly linked to lifestyle and body-mind dynamics and is resistant to conventional medical treatment, insomnia deserves much greater consideration from integrative medicine researchers and practitioners.

• In fact, a National Health Interview Survey reported that 1.6 million adults already use complementary and alternative medicine (CAM) to treat insomnia.

Therapeutic Review : Insomnia

Reduce Body Noise

• Directly address all comorbid conditions, especially primary sleep disorders, depression, chronic pain, and women's health issues. Evaluate and manage sleep side effects of all medications. Evaluate and manage alcohol, caffeine, and other stimulant use.

• Melatonin: 0.3 to 0.5 mg at bedtime, especially if the patient may have an associated circadian rhythm disorder

• Avoid sedative-hypnotics, and use complementary and alternative medicine sleep aids as needed, preferably on a short-term

(2- to 4-week) basis. Consider one or a combination of the following:

• Valerian, for adults: 300 to 900 mg standardized extract of 0.8% valerenic acid or as a tea of 2 to 3g of dried root steeped for 10 to 15 minutes and taken 30 to 120 minutes before bedtime for 2 to 4 weeks to assess effectiveness

• Hops: in a 5:1 ethanolic extract, ½ to 1 dropper full, 30 to 60 minutes before bedtime

Reduce Mind Noise

• Encourage patients to select and engage in a daily relaxation practice. The 4-7-8 relaxing breath exercise is an easy and effective option.

• Use stimulus control therapy for sleep efficiency lower than 85%.

• Evaluate and discuss basic dysfunctional beliefs and thoughts about sleep. Refer the patient to a behavioral sleep medicine specialist for more elaborate cognitive restructuring therapy as needed.

• Encourage dream recall by limiting "dream thieves," and promote daily dream journaling and participation in dream support groups. Refer patients with chronic nightmares to a behavioral sleep specialist for image rehearsal therapy.

Reduce Bed Noise

• ⁠Recommend reduction of bedroom toxicity from beds, bedding, and furnishings, as well as air filtration with high-efficiency particulate air (HEPA) filters or houseplants. Encourage evaluation of and protection from electromagnetic fields.

• Urge the patient to maintain a regular sleep-wake schedule, including on weekends. The patient should simulate dusk by dimming lights or using blue blocker technology.

• 1 to 2 hours before sleep, and sleep in total darkness.

• Exposure to morning light is important.

• Encourage patients to create a sense of sanctuary by establishing the bedroom as a stress-free and work-free zone, limiting exposure to stressful imagery and clocks, ensuring a sense of personal safety, and maintaining peace with bed partners.

Relaxing Breath Exercise

1. Place the tip of your tongue against the ridge behind your front teeth and exhale completely through your mouth.

2. Inhale through your nose for a count of 4.

3. Hold your breath for a count of 7.

4. Exhale through your mouth with a swooshing sound to the count of 8.

5. Repeat this cycle three more times for a total of four breaths.

The ratio of 4:7:8 is key, not the actual time spent on each breath cycle.

Practice at least twice daily, beginning with no more than four breath cycles at one time for the first month and increasing to eight breath cycles afterward if desired.

This exercise can be used to increase presleep relaxation and to facilitate sleep onset in bed.

Comorbid Primary Sleep Disorders  

• Restless Legs Syndrome (RLS)  

• Periodic Limb Movements in Sleep (PLMS)  

• Gastroesophageal Reflux Disease (GERD)  

• Sleep-Phase Disorders  

• Narcolepsy  

• Obstructive Sleep Apnea (OSA)  

• Nocturia  

Medications That Can Interfere With Deep or Rapid Eye Movement Sleep  

• Alcohol

• Antiarrhythmics

• Anticonvulsants

• Antihistamines

• Appetite Suppressants

• Benzodiazepines

• Bronchodilators

• Caffeine  

• Carbidopa/Levodopa

• Corticosteroids

• Diuretics

• Decongestants

• Estrogen

• Lipophilic Beta Blockers

• Monoamine Oxidase Inhibitors

• Nicotine

• Pseudoephedrine

• Selective Serotonin Reuptake Inhibitors

• Sedatives

• Statins

• Sympathomimetics 

• Tetrahydrozoline

• Thyroid Hormones

• Tricyclic Antidepressants

Pro-Tip  

Chronic insomnia often results from excessive wakefulness rather than insufficient sleepiness. Elevated metabolic rate, sympathetic overactivation, and chronic inflammation contribute to chronic cognitive-emotional hyperarousal.  

Key Insight

• A good night's sleep stems from a good day's waking.  

• Letting go of excessive wakefulness can reduce insomnia.  

• Promoting dreams is essential, akin to emphasizing the taste of food for good nutrition.  

• Sleep disorders reflect a clash between nature and culture—cyclic versus linear time.  

Common Medications for Insomnia  

Over-the-Counter Agents  

• Diphenhydramine  

• Doxylamine  

Benzodiazepines  

• Estazolam  

• Flurazepam  

• Quazepam  

• Temazepam  

• Triazolam  

Nonbenzodiazepine Hypnotics  

• Eszopiclone  

• Zaleplon  

• Zolpidem  

Melatonin Receptor Agonists  

• Ramelteon  

Antidepressants  

• Amitriptyline  

• Doxepin  

• Trazodone  

• Mirtazapine  

Other Agents  

• Clonidine  

• Gabapentin  

• Quetiapine  

• Sodium Oxybate (GHB)  

Common Side Effects of Sedative-Hypnotics  

• Dependence  

• Tolerance  

• Damaged Sleep Architecture  

• Diminished Deep Sleep  

• REM Sleep Suppression  

• Parasomnias  

• Anterograde Amnesia  

• Morning Hangover  

• Undermined Self-Efficacy  

• Rebound Insomnia  

• Increased Risk of Falls  

• Cognitive Impairment  

• Increased Mortality  

Strategies for Improving Sleep  

• Reducing Body Noise  

• Manage comorbid conditions, including sleep disorders, depression, and chronic pain.  

• Address medication side effects.  

• Regulate alcohol and caffeine use.

Dysfunctional Sleep Beliefs  

• Challenge thoughts such as "I must sleep 8 hours every night" or "I’ll have a terrible day if I don’t sleep well."  

Promoting Healthy Dreaming  

• Identify and address dream disruptors.  

• Journal dreams or join dream circles.  

Mind Noise Reduction: CBT for Insomnia  

• Sleep hygiene education  

• Cognitive restructuring  

• Stimulus control therapy  

• Sleep restriction therapy  

• Relaxation practices  

Stimulus Control Therapy Instructions  

1. Go to bed only when sleepy.  

2. Use the bedroom only for sleep and intimacy.  

3. Avoid clock-watching.  

4. Leave the bedroom if awake for more than 15 minutes and engage in restful activities until sleepy.

5. Maintain a consistent wake time.  

6. Avoid napping until nighttime sleep normalizes.  

Reducing Bedroom Toxicity  

• Avoid pesticide-laden fabrics and synthetic materials.  

• Use HEPA filters or houseplants for air quality.  

• Limit electromagnetic field exposure.  

Regulating Circadian Rhythms  

• Use phototherapy and maintain a regular sleep-wake cycle.  

• Dim lights or use blue blockers 1–2 hours before bed.  

• Sleep in total darkness or use a sleep mask.  

Creating a Sense of Sanctuary  

• Keep the bedroom stress-free and work-free.  

• Avoid stressful imagery before bed.  

• Ensure personal safety and harmony with sleep partners.  

Prevention Prescription  

• Recognize and prioritize the value of sleep.  

• Maintain regular relaxation practices and morning light exposure.  

• Sleep in darkness and consider low-dose melatonin if needed.  

Key Web Sources

• American Academy of Sleep Medicine: http://www.aasmnet.org/

• Society of Behavioral Sleep Medicine: http://www.behavioralsleep. org/

• Epworth Sleepiness Scale: http://epworthsleepinessscale.com/

• Fatigue Severity Scale: http://www.medscape.org/viewarticle/ 472869

• Sleep diary forms: http://www.sleepeducation.com/pdf/sleepdiary.pdf or http://sleep.buffalo.edu/sleepdiary.pdf