One never thinks of sleep as a problem until one has lost the ability to sleep deeply and awaken refreshed. The ancients valued the benefits of sleep so highly that they believed it was a gift from their gods. The Greeks believed that Hypnos was the God of Sleep. He is generally depicted as a benevolent figure that brought the restorative gift of sleep to mortals and gods alike. Morpheus, the god of dreams was the child of Hypnos. There is no culture that does not have a set of beliefs about the value of sleep and the health problems that when it is disrupted.

“Now, blessings light on him that first invented this same sleep! It covers a man all over, thought and all, like a cloak; it is meat for the hungry, drink for the thirsty, heat for the cold, and cold for the hot. It is the current coin that purchases all the pleasures of the world cheap, and the balance that sets the king and the shepherd, the fool and the wise man, even.” From “Don Quixote” by Miguel de Cervantes Saavedra, (1547-1616).

In the modern age we want to feel awake, energetic and vital at all times. We want our sleep to be brief but effective. Our physicians have described a variety of sleep related disorders or diseases. We have built a technology of diagnosis and treatment that has an estimated direct cost of $14 billion in 1995. This includes the cost of visits to physicians and other health care providers, prescription and non-prescription medication. There are many indirect costs related to insomnia. School and job performance is impaired. Insomnia is associated with functional impairment such as impaired memory and concentration, decreased ability to accomplish daily tasks, and diminished capacity to solve problems. There is a strong association between Insomnia and absenteeism, increased use of medical services and poorer overall health. Insomnia is associated with emotional problems such as depression and anxiety. Chronic illnesses such as Fibromyalgia and Chronic Fatigue Syndrome are associated with insomnia. There is an increased association of insomnia and motor vehicle accident. Approximately 200,000 motor vehicle accidents occur each year because of fatigue and excessive daytime somnolence. Many industrial accidents are linked to impaired performance secondary to sleep disturbance. Major catastrophes such as the Three Mile Island Nuclear Meltdown the Challenger Space Shuttle disaster and the grounding of the Exxon Valdez have been related to the adverse effects of sleep deprivation.

People with sleep disorders have a variety of complaints. The most common complaints are insomnia and excessive daytime sleepiness, (hypersomnolence). Insomnia can be thought of as inadequate quantity or quality of sleep with the consequence of daytime fatigue. The pattern of insomnia may vary from individual to individual. Individuals may experience some or all of the common problems of insomnia. These include difficulty in initiating sleep, difficulty maintaining sleep, awakening too early or the experience of non-restorative sleep, (not feeling well rested after sleeping).

The average amount of sleep required for good health is between 7 to 8 hours per night. Some individuals will feel well rested with 5 hours while others may require 10 hours to feel refreshed and energetic through the day. The correct amount of sleep may vary with factors such as season, illness and stress. The appropriate amount of sleep is the amount that allows you to awaken refreshed and function throughout the day without excessive drowsiness and with good concentration.

In the best practice of medicine, Sleep Quality is an important factor in maintaining good health and restoring health in those with chronic illness. Sleep and Rest are one of the cornerstones of good health practice along with Diet, Exercise, and Detoxification. Restorative Sleep and Rest have an impact on our hormonal function and immune function. Scientists have demonstrated that sleep disturbance can cause hormonal dysregulation that may make individuals more vulnerable to developing cancer. Sleep disturbance can be associated with an increased incidence of infections due to immune disturbance, diabetes, stroke and heart disease.

Insomnia may be of short, intermediate or long-term duration. It is classified into subgroups that help health care practitioners address the problem.

Adjustment Sleep Disorder: This is typically a problem of difficulty falling asleep and staying asleep brought on by a new stress such as loss of a job or family illness. The problem will usually resolve itself. When the stressful situation persists, the sleep problem may become chronic and interfere with general health.

Psychophysiological Insomnia: This type of sleep disorder refers to a learned association between the attempt to sleep and physical or mental symptoms that prevent sleep. In a sense the individual psyches themselves out of a good night sleep. Behavioral therapies can be very effective in correcting this problem.

Sleep State Misperception: This is a condition where the individual believes they have a problem when they do not. Reassurance is often helpful in these situations.

Insomnia Associated with Medical and or Psychiatric Conditions: Insomnia may be caused by chronic health conditions such as chronic pain, cardiac problems, asthma, gastroesophageal reflux, and neurological diseases. Day time fatigue may be part of a primary sleep disorder such as sleep apnea, narcolepsy, circadian rhythm disturbances or restless leg syndrome. Medications used to treat health problems may cause insomnia. Non-prescription drugs such as alcohol, caffeine and nicotine may cause sleep disturbance.

Sleep deprivation: This is a phenomenon that is common in our society. There are just to many things to do in a day and the day extends itself into night. We cheat and do not get to bed at a reasonable hour. We accumulate sleep deprivation. We try to deal with the daytime fatigue that results by using stimulants such as caffeine. The treatment for this is common sense. Plan a peaceful evening and get to bed early.

Primary Sleep Disorders: Primary sleep disorder are important to diagnose since there may be specific treatment that will provide improvement in the condition and the secondary day time fatigue.

Obstructive Sleep Apnea is a condition where there is a slowing and interruption of breathing during sleep. This is often associated with snoring. This is caused by a narrowing or partial collapse of the upper airway. In most cases it is related to obesity and improves with weight reduction. The problem is suspected when the individual presents with daytime fatigue and cognitive impairment, (trouble thinking clearly), and a history of snoring with interrupted breathing. It is diagnosed in a sleep lab. Treatment options include weight loss, surgery and continuous positive airway masks.

Narcolepsy is a disorder characterized by excessive daytime sleepiness and disturbed nocturnal sleep. Secondary symptoms included cataplexy, hypnagogic hallucinations and sleep paralysis. We diagnose this with a Multiple Sleep Latency study. Conventional medicine treats this problem with medication quite effectively.

Circadian Rhythm Disorders refers to sleep disorders characterized by the inability to sleep at traditional times. Adolescent often experience delayed sleep phase syndrome, (sleep-onset insomnia and difficulty waking at the desired time in the morning). The elderly often experience advanced sleep phase syndrome, (excessive sleepiness in the evening and undesired early morning awakening). Shift workers who constitute 25% of our work force often experience sleep phase disorder problems.

Restless Legs Syndrome is characterized by an unpleasant sensation in the legs and feet that is improved with movement of the legs. In extreme cases there is cramping and pain. This often causes sleep disturbance.

Diagnosis

Diagnosis of persistent sleep disorders is best done with the help of a Health Professional. There are some simple questions to ask yourself that may be helpful in guiding you to a more restful sleep.

• Do you use caffeine, tobacco, or alcohol? Is the use associated with sleep disturbance?

• Are you using prescription medications that may interfere with restful sleep? Check with your doctor.

• Is the sleep environment conducive to sleep? Think about noise levels, light exposure and temperature.

• Do you awaken in the middle of the night hungry? This may be a sign of insulin resistance and secondary hypoglycemia. Dealing with these issues may improve sleep quality.

• Does your partner observe loud snoring, gasping, and choking or excessive leg movement?

• Do you have underlying medical problems that may interfere with sleep?

• Do you experience excessive daytime fatigue, poor energy, impaired ability to concentrate or poor memory?

Bring your concerns to your health care practitioner.

Treatment Strategies

Sleep Hygiene Education

This is a technique to help patients with insomnia identify lifestyle and environmental factors that may interfere with sleep. The instructions include:

• Avoid stimulants such as caffeine and nicotine 12 hours before bedtime.

• Do not use alcohol as a sleep aid and avoid alcohol before bedtime. While alcohol may promote sleep onset it interferes with sleep quality.

• Do not exercise closer than 3 hours before bedtime. Regular exercise is encouraged.
  Minimize light, noise and extreme temperatures during sleep.

• Eat a light snack before bed if hungry.

• Do not watch the clock.

• Do something relaxing before bedtime.

Cognitive Therapy

Cognitive therapy attempts to identify dysfunctional beliefs about sleep and replace them with more reasonable beliefs and expectations about the sleep process.

Prescription Medications

There are a variety of sedative-hypnotic medications that are useful in promoting sleep. In general, these medications should be used for short periods of time. While they induce sleep they do not allow for the natural stages of sleep to develop. Antidepressant medications may be used long term in patients with clinical depression. In many cases there is an improvement of sleep quantity and quality with treatment depression. Sedating antidepressants include amitriptyline, doxepin, imipramine, nefazadone, trazadone, and mirtazapine. There are new medications available that are effective in improving sleep quality. These include sodium oxybate and tiagabine. They do not have an addiction potential and can help induce the deepest stages of sleep. This is important because it can help normalize the production of reparative hormones such as growth hormone. This should result in an overall health improvement.

OTC Medications

Most OTC medications that are used to promote sleep have a sedating antihistamine such as benadryl as the active ingredient. Used occasionally they are safe. There are not advised for chronic use.

Complementary/Alternative Medicine Strategies

CAM strategies include attention to diet, exercise, stress avoidance and reduction, and detoxification. These factors form the foundation of any health-enhancing endeavor.

Dietary issues include:

• Emphasizing high protein foods at breakfast and lunch while emphasizing high carbohydrate foods at dinner and in the evening.

• Avoiding the stimulants such as caffeine in the evening.

• Avoiding the sleep disrupters such as alcohol and caffeine.

• Identifying and avoiding foods that may be causing sensitivity, allergy or intolerance reactions.

• Identifying the individual with Insulin Resistance and correcting the situation. This will often manifest as awakening with hunger.

Exercise issues include:

• Getting a reasonable amount of exercise in the morning or afternoon while avoiding exercise within three hours of bedtime. This will help set the normal sleep/wake cycle.

• Learning exercises that balance energy and reduce stress such as Yoga, Tai Chi or Chi Gong
  

Stress Reduction Strategies include:

• Creating a healthful sleep environment: Ambient light and noise should be minimized.

• Environmental pollutants such as dust, mold, animal dander and chemical toxins should be reduced.

• Clothing and blanketing should be non-toxic and comfortable. Air temperature should not be excessively hot or cold. Avoid stimulants such as TV in the bedroom.

• Developing pleasant evening routines before bedtime such as a relaxing bath or sauna

• An Epsom Salt Bath, (2 cups of Epsom Salts in a hot bath), for 15-20 minutes will help relax muscle

• Learning relaxation or meditation techniques to relieve stress and daytime fatigue

• Yoga practice

• Learning to resolve stressful situations at home or work and not letting them linger

• Doing things for others; volunteering

Detoxification Strategies include:

• Identifying the individuals’ burden of environmental intoxicants such as heavy metals, pesticides, and herbicides. When a toxic burden is identified steps should be taken to remove the toxin while minimizing further exposure. Chronic intoxications can be a major contributor to disturbed sleep.
   

• Other sources of intoxication can be from foods we eat, (allergy, intolerance, contamination), dysbiosis, (abnormal living organisms in a bowel), or abnormal absorption of products of bacterial metabolism from our bowel due to excessive intestinal permeability. Identifying and correcting these problems can be a factor in improving general health and restorative sleep.

Nutritional Supplements that may improve Sleep:

Tryptophan is an amino acid. It had been readily available as an OTC supplement. This product was removed from the OTC market when an improperly prepared batch caused serious health problems as a result of contamination. It is still available with a physicians prescription from a Compounding Pharmacist. It can be very effective for the individual with sleep disturbance and associated depression. It should only be used with a physicians supervision.

5HTP is a metabolic product of Tryptophan produced in the body from Tryptophan. It is available OTC. It may be helpful in promoting sleep in a dose of 50 to 150 mgs. taken at bedtime. It can take 2-4 weeks to work. It will not work promptly. It is believed to help increase serotonin levels in the brain. In doing so it may be useful for people with depression. Since depression is so often a consideration in people with chronic sleep problems, I recommend that such individuals seek the help of a health care practitioner when using these products.

Magnesium supplementation can be useful in promoting sleep. It can be particularly useful in individuals with Restless Leg Syndrome, Nocturnal Leg Cramps or Spasms that disturb sleep. A typical dose is 300-400 mgs in the evening. Magnesium may cause a stomach upset or loose bowels. We recommend high quality magnesium aspartate, as it seems to be more easily tolerated.

Vitamin K in a large dose may be helpful in reducing pain. In individuals who experience sleep disturbance secondary to chronic pain I may suggest Vitamin K in a dose of 5-10 mgs. This will not work quickly. It may take 4-6 weeks to create improvement.

Herbal Supplements that may improve sleep:

Valerian Root has been shown to be effective in promoting sleep induction and sleep quality. It must be used regularly for 2-3 weeks in order to have its effect. Do not expect a prompt effect. The therapeutic dose will vary with the type of preparation, (extract, tincture or tea). The quality of the product is very important in maximizing chances for benefit without side effects. We use products that are tested by an independent laboratory after the manufacturer has encapsulated them.

Other natural products that can be used to aid individuals with sleep problems include:

•  Aspirea,

• Indian Pipe,

• Snake Root,

• Lemon Balm,

• Hops,

• Skullcap and

• Theanine

We will often combine different herbal products to suit the individuals’ unique needs. A skilled Herbalist will attempt to treat the underlying imbalance and not just the symptom. We are fortunate to have a consultant who is a Maryland State Licensed Pharmacist and a Master Herbalist.

Hormonal Supplements that may improve sleep:

Melatonin is a hormone secreted by the Pineal Gland. I refer you to the chapter on Melatonin on our web site. It can be very effective for sleep induction and quality in a dose of 0.5-3.0 mgs. I usually suggest the lower dose as it is more physiological. It can be very effective for people with sleep phase disturbances such as the elderly, teenagers, travelers or shift workers.

Progesterone is a hormone that is produced by the Adrenal Gland, Ovaries and Brain Tissue. In appropriate levels can reduce anxiety and allow individuals to relax as well as deepen sleep. Many women suffer from a phenomenon that has been described as Estrogen Dominance. The symptom complex can include insomnia, anxiety, mood lability, fluid retention and bloating. Progesterone supplementation may be helpful in this case. Visit the chapter on Progesterone on our web site.

Growth Hormone is a hormone that promotes growth in the young. It promotes tissue health in the adult. Growth Hormone deficient adults often experience sleep disturbance and daytime fatigue. Growth Hormone supplementation can be helpful in improving sleep quality and overall energy levels. See the chapter on Growth Hormone on our web site.

Hormonal therapy is best done by taking into consideration the balance of all the hormones, the interactions between the hormones, the factors that effect hormonal metabolism and activity, (diet, nutrients, exercise, detoxification process, stress).

Acupuncture:  Acupuncture that addresses underlying energy imbalance can be very effective in restoring healthy sleep patterns.

Simple Steps:

First do the things you can do. Try the simple things we have outlined that deal with life style change. Check with a health professional to make sure that a prescription medication or OTC product is not causing sleep disturbance. You can get a consult with Lynn Shoemake, (Pharmacist/Herbalist), in person or by phone. Consider non-prescription nutritional products, herbal products and hormonal products. Consider prescription medications when necessary. The use of a prescription medication should not deter you from improving lifestyle and environment to optimize their effect.