Some Suggestions for Dealing with Insomnia

“I seem not to have the shut down switch in my brain.” She is worried about taking medications, and wonders if there is anything else that she can do to help herself.

It is always unwise to make specific recommendations about someone without seeing them face-to-face, and the evaluation of a problem like this will normally take several hours. But the points that she raises have a great deal of relevance for so many people that I thought that a few comments would be helpful and equip everyone reading this with some information to discuss with their healthcare providers.

As usual, I think that it is a good idea to look at the question from the multiple dimensions of physical, psychological, social, subtle and spiritual. They are all inter-related, so dividing them up is simply a convenient way to help us think through the problem.

Before we do anything, we have to try and find out why someone has problems with sleep, and that may need investigations up to and including a sleep study.

The first thing is that my correspondent is female and likely either menopausal or perimenopausal. That is important, because as most women know, hormones have potent effects on sleep. It is not just that uncomfortable hot flashes can wake a person; it is also a direct effect of estrogen and probably of some of the releasing hormones in the hypothalamus. Hormone replacement therapy alone, does help some women but by no means all. Even at the physical level we see the general principle that there is rarely one cause for one problem. Typical menopausal sleep disturbances include a difficulty in falling asleep, and around 20% of menopausal women report that they sleep less than six hours a night. There is also some degradation in what we call sleep efficacy and an increase in deep slow wave sleep. Estrogen has effects on nasal mucosa, and when estrogen levels fall obstructive sleep apnea is more likely to occur. A major physical and psychological issue is that insomnia may become a learned habit that can persist even in the face of the best treatments.

This leads me to the second dimension, and that is psychological. The writer of the letter mentioned that she couldn’t turn off her thoughts. You would be amazed at how frequently I have been asked to consult on someone with a sleep problem and the individual has never been asked the question, “What is it that stops you falling asleep?” I have seen countless people prescribed sleeping tablets, when the real problem was anxiety or some other nasty problem that needed to be tackled first. In a moment I am going to make some suggestions that will try and help with both sleep and the ruminations and anxieties that may be contributing to its disturbance. Similarly, I have known a great many people whose sleep problems were the result of relationship difficulties or of something as simple as one person being a night owl and the other an early morning riser.

I always start with some simple sleep hygiene:

1. Stress management
2. Exercise a couple of hours before retiring
3. Keeping mentally stimulated until it is time for bed
4. Don’t go to bed until you are tired
5. No caffeine, alcohol or nicotine after 6pm. (Preferably, of course, no nicotine ever!!) {Remember that many over the counter painkillers contain caffeine, as does chocolate}
6. There are some specific dietary recommendations for helping with sleep, and I shall write about those on a future occasion
7. Try to keep the bedroom atmosphere relaxing, and establish a sleep ritual
8. If you cannot sleep, get up and do something relaxing: struggling to go to sleep is virtually impossible.
9. Always get up at the same time in the morning, to try and re-set your brain, and as soon as you get up, be exposed to as much bright light as possible.

1. Start by lying on your left side for 5-10 minutes and then roll onto your right side. This appears to work by exploiting the so-called nasal cycle, which I shall write more about on a future occasion.
2. Still on the subject of the nose, one of the reasons that aromatherapy can be helpful, is because smell is unique amongst our senses, in that it is the only one that is not filtered by the thalamus. The regions of the brain that respond to smells are also directly related to some of the memory centers. The result is that smells can evoke memories extremely rapidly. You will probably have had the experience of smelling a perfume or cologne and instantly remembering someone who wore it in the past. This close linkage of smell and memory has enormous survival advantages: the smell of a predator can cause us to respond extremely rapidly. We can also use this knowledge to our advantage. Lavender has been used as a sleep aid for centuries. You can try putting a few drops of lavender oil on a cloth on your night-stand. Or you can use an electric diffuser or aromatherapy lamp. When I was growing up, we grew lavender and would put sprigs of it in the bed linens. It certainly seemed to help.
3. Some people have found that melatonin can be very helpful, and it is readily available. Discuss it with your health care provider.
4. Here is an old trick from traditional Chinese medicine. If you cannot sleep, soak a washcloth in cold water, lie down and put it on your abdomen for about ten minutes. I was taught that this works by pulling excess energy out of your head and neck down into the abdomen. There’s not a shred of scientific evidence that the technique works, but it does surprisingly often.
5. If people who are good at visualization, some have reported great success by creating a picture of a warm, calm and relaxing place. And not just a picture, but also a five senses experience. It has to be personal, and perhaps even a place to go back to on a regular basis. When I first learned to do hypnotherapy I was put into a light trance by one of my teachers. To this day, more than 25 years later I can still vividly recall the experience of being told that I was drowsing on a grassy knoll on a warm summer’s day on the Downs of Southern England, and actually feeling that I was there. I can still evoke the memory at will and I’ve made it more detailed over time. If you are a visualizer, try that.
6. Another technique that I learned from an early teacher, is to review the day backwards. Remembering what you did immediately before going to bed, and before that and so on. A simpler and often effective technique is just to start slowly counting backwards from 100.
7. Herbs: There are three that are widely used, and for which there is some research base. There is good evidence that the herb Valerian can induce drowsiness, and it is widely used – even by doctors – in France and Germany. An important point about valerian is that it is poorly absorbed and chemically and thermally unstable. So it needs to be kept cool, and used fairly soon after it is prepared. As with all herbs, Valerian has side effects and can interact with prescription medications and alcohol, so it really is essential to discuss its use with your health care provider. The same goes for the other two widely used herbs: Hops and Passionflower.
8. There is some evidence, though it’s not that strong, that taking a combined calcium/magnesium supplement (500mg calcium and 250-500mg magnesium) an hour before bed helps some people.
9. I recommend massaging your facial muscles before lying down to sleep. Not only does this reduce muscle tension, but also the face is covered in acupuncture points, and so that may be another reason why it can help.
10. Do not read or watch television in bed, but listen to a little calming music before retiring.

I do hope that will help you in your discussions with your health care provider. And I am always interested in hearing other suggestions, particularly if there is some research to back them up.

Technorati tags: Insomnia, menopause, herbal medicine, sleep hygiene, insomnia remedies, women’s health