Paradoxical Insomnia: A Second Look at Treatments

Paradoxical insomnia: a diagnosis given to people whose sleep studies show they sleep a normal amount but who perceive they sleep much, much less. When I wrote about it in 2015, the word was that cognitive behavioral therapy (CBT)—the gold standard in treatments for insomnia—might not be an effective treatment for it.

But a brief testimonial that recently appeared in American Family Physician argues otherwise. Here’s an update on this puzzling sleep disorder.

Paradoxical insomnia may respond to treatment with CBT & therapies lowering arousalParadoxical insomnia: a diagnosis given to people whose sleep studies show they sleep a normal amount but who perceive they sleep much, much less. When I wrote about it in 2015, the word was that cognitive behavioral therapy (CBT)—the gold standard in treatments for insomnia—might not be an effective treatment for it.

But a brief testimonial that recently appeared in American Family Physician argues otherwise. Here’s an update on this puzzling sleep disorder.

A Subjective-Objective Discrepancy

Time and again we hear that people with insomnia tend to underestimate sleep duration. Up to 50 percent of the time, the electroencephalograms (the graphic records of brain waves produced during overnight sleep studies) of insomnia sufferers reporting insufficient sleep look the same as those of normal sleepers, registering 7 or 8 hours of sleep.

But in people with paradoxical insomnia, the discrepancy between their sleep study results and their subjective assessment of their sleep is huge. The woman whose story appeared in American Family Physician perceived that she was routinely “awake all night.” Yet when she finally went in for an overnight sleep study, the record of her brain waves showed she’d slept a total of 7 hours and 18 minutes. She couldn’t believe it.

A Heavy Burden

You might think, since paradoxical insomniacs are getting a normal amount of sleep, that their insomnia symptoms would be less severe than those of “objective” insomniacs, whose sleep studies show they get less (sometimes considerably less) than 7 or 8 hours. Paradoxical insomnia may sound like “insomnia lite.”

Apparently it isn’t. Research has shown that paradoxical insomniacs tend to be more confused, tense, depressed, and angry than normal sleepers. They also have a higher metabolic rate, which suggests an overall higher level of arousal.

In-depth analyses of brain activity at night attest to this heightened arousal. Compared with objective insomniacs, paradoxical insomniacs experience more high-frequency activity, and less low-frequency activity, in the brain at night. Their sleep is light and vigilant.

Yet it’s often hard for people with paradoxical insomnia to convince others that anything is wrong. When the woman writing in American Family Physician complained about not having slept all night, her husband countered with insistence that she’d slept soundly the whole night. Her friends and colleagues were skeptical too, noting that she had a normal amount of energy and competence at work. She felt increasingly tormented—“not only because of the insomnia,” she wrote, “but also because of a loss of trust from my husband and friends. They said they wondered whether I was pretending just to get sympathy.”

What Could Be Wrong? What Can Be Done?

Scientists can’t explain exactly what the problem is. One hypothesis holds that paradoxical insomnia has something to do with sleep quality, and that treatments that train paradoxical insomniacs to perceive sleep when they’re objectively determined to be asleep may help. (See my other post about paradoxical insomnia here.) But adjusting people’s perceptions may not necessarily resolve all their insomnia symptoms or improve their long-term health.

Other researchers have proposed that paradoxical insomnia occurs due to heightened brain activity during sleep, a condition which is accurately perceived by those who experience it but will require more sophisticated measures to assess scientifically. If it’s true that in paradoxical insomnia the main barrier to satisfying sleep is excessive brain activity and vigilance at night, then therapies designed to lower arousal levels—exercise, yoga, meditation—may help.

How About CBT for Insomnia?

Some experts have expressed doubts about whether CBT for insomnia (CBT-I) has the potential to work as well for paradoxical insomnia as it does for the more common psychophysiologic insomnia. The main value of CBT-I is its ability to help people fall asleep more quickly and decrease nighttime wake-ups. At least when their sleep is assessed objectively, paradoxical insomniacs don’t usually have these particular problems.

But CBT-I also helps to dispel negative beliefs and excessive worry about sleep, which can make any type of insomnia worse. It was an effective insomnia treatment for the woman writing in American Family Physician. “After receiving cognitive behavior therapy,” she wrote, “I began to feel much better and now am able to sleep well most of the time.”

So if it feels like you’re hardly sleeping at all, consult a sleep doctor or a sleep therapist for a proper diagnosis and help in improving your sleep. There may be more insomnia treatment options than you think.

If you feel you’ve benefited from reading this post, please like and share on social media. Thanks!

Tips for Stressed-Out Caregivers Seeking Better Sleep

Occasionally I get emails from people with take-charge, type A personalities wondering what to do about insomnia. Full of self-reliance, they’ve often scoured the internet for remedies—and tried every one—or amassed a mountain of books about sleep—and read them all—to little avail. Can I suggest anything that might help?

Here is Geri’s story (abbreviated to save space) and my response.

Insomnia can be relieved by focusing on stress reduction and self-careOccasionally I get emails from people with take-charge, type A personalities wondering what to do about insomnia. Full of self-reliance, they’ve often scoured the internet for remedies—and tried every one—or amassed a mountain of books about sleep—and read them all—to little avail. Can I suggest anything that might help?

Here is Geri’s story (abbreviated to save space) and my response.

A Caregiver’s Hectic Life

I have had insomnia since 2005. I have four children (13, 10, 9 and 7) and at time of onset only had one. Triggered by changing jobs and trying to get pregnant—so stressful! I am a community mental health nurse. I have a caseload of 22 adults with psychosis and am their primary support. . . . [At night] it can take 2 hours for me to fall asleep and then I usually wake between 12 and 2 a.m. I do not go back to sleep. . . . I am naturally an over thinker, I do stress easily and worry a lot. . . . I’ve never been a great sleeper but yes I used to sleep. We are struggling financially so not working is not an option. . . . I have a library of books on sleep, have spent hundreds of pounds on various remedies and treatments—but alas nothing really seems to help. Can you suggest anything?

Geri had a lot on her plate. She was on the go all the time, caring for patients during the workday and children at night. Her busy schedule didn’t leave much time for self-care.

She knew what she needed: fewer responsibilities. If she won the lottery, she said, she’d resign from nursing, fix up her house, and be the mother and relaxed partner she’d like to be. But that was not in the cards.

Adding Things In, Cutting Things Out

Despite her time constraints, Geri was resourceful in looking for insomnia remedies. She’d also established some habits conducive to sound sleep: eating healthy foods, getting plenty of exercise by cycling to and from work and her patients’ homes, and practicing mindfulness.

But she’d also tried a raft of insomnia remedies that didn’t seem to help, from herbs and homeopathic insomnia cures to acupuncture and CDs with “odd sleep-inducing sounds.” When Geri wrote to me, she was planning to ramp up her efforts to improve her sleep by:

  • Adding high-intensity interval training to the cycling she did everyday (though it was a struggle to find the energy for this activity)
  • Cutting out alcohol completely (which, in times of desperation, she used to get to sleep)
  • Cutting out processed sugar, including the “crap biscuits” (cookies) she was prone to eat when super tired

What did I think?

Regimentation, Stress and Sleep

My immediate reaction on reading Geri’s story was that I could never do half of what she does and expect to sleep consistently well. With so many responsibilities I’d be popping Valiums every day!

Seriously, though, Geri’s sleep problem may have been related to chronic stress and the double duty she was doing as caregiver for her patients and her children (i.e., caregiver stress). Even so, her inclination was not to find ways to make her responsibilities more manageable. It was to do still more, adding high-intensity interval training to an already busy schedule and restricting an already healthy diet still further.

I wondered if the restrictive regimen she was about to impose upon herself would sooner or later become yet another source of stress. It’s true that exercise is beneficial to sleep. But nowhere has it been suggested that a person should have to cycle to and from work and do high-intensity interval training to get better sleep.

Dietary Choices and Sleep

It’s also true that what we eat can affect our sleep. But having a cookie now and then is probably not going to make a difference. There’s a lot of information now suggesting that overindulgence in simple carbohydrates is harmful to health. We shouldn’t routinely have Hostess cupcakes washed down with Pepsi for lunch. But cut out sugar completely? I follow the literature on insomnia and sleep pretty closely, and not one study I’ve seen has shown that cutting sugar out altogether from our diets will improve sleep.

Likewise, it’s smart to avoid using alcohol for sleep. But a glass of wine at happy hour is probably not going to have much impact on the night at all. It sounds punitive for Geri to try to regiment her life still more than it already is.

Reduce Stress With Better Self-Care

It could be that Geri would benefit from consulting a sleep doctor or a sleep therapist and that cognitive behavioral therapy for insomnia, administered by a trained professional, might help. A sleep study might uncover an underlying sleep disorder (or show she was getting more sleep than she thought).

But I think Geri’s sleep would improve if she were to reduce her stress by engaging in more nurturing self-care. She’s got a head start on some of the ways to do this but other readers may not:

  • Take half an hour a day for yourself and do something purely for pleasure (gardening, reading a novel, playing the piano)
  • Learn and use stress reduction techniques such as meditation, yoga, or Tai Chi.
  • Stay current with your own healthcare needs.
  • Eat regular, healthy meals.
  • Exercise daily.
  • Take time off when you can.
  • Maintain ties with friends and supportive family members, and when possible seek and accept their support.
  • Seek counseling when you need it or reach out to friends

If you’re a full-time caregiver, what’s the best way you’ve found to take care of yourself?

Coffee: The Sleepless, Too, Can Enjoy the Benefits

I love coffee and I’m always glad to hear coffee is beneficial to my health. Two new studies—one of humans and the other of mice—add to this growing body of knowledge.

Yet coffee contains caffeine, and people with insomnia are often advised to cut down on caffeine because it interferes with sleep. Is there a middle course the sleepless can steer to avoid the harms and reap the benefits?

Coffee | insomnia sufferers can enjoy health benefits & avoid the harmsI love coffee and I’m always glad to hear coffee is beneficial to my health. Two new studies—one of humans and the other of mice—add to this growing body of knowledge.

Yet coffee contains caffeine, and people with insomnia are often advised to cut down on caffeine because it interferes with sleep. Is there a middle course the sleepless can steer to avoid the harms and reap the benefits?

Decaf is always an option. Caffeinated coffee may be OK, too—if you’re willing to experiment. Here’s more on that following a brief look at the new findings:

Coffee Reduces Mortality

The latest study of coffee and mortality found that coffee drinkers live longer than non-coffee drinkers. In this large, multi-ethnic study, people who drank one cup a day were 12% less likely to die than non-coffee drinkers. The odds were even better for people who drank two or three cups a day: they were 18% less likely to die.

The particular chemical or compound in coffee that protects against heart disease, cancer, respiratory disease, stroke, diabetes, and kidney disease is still unknown. But it probably isn’t the caffeine. Coffee’s life-protecting benefits were significant for people who drank caffeinated coffee and for those who drank decaf. They were significant for smokers and non-smokers; African-Americans, Asians, Latinos, and whites; and people of all ages.

Caffeine Reduces Pain Sensitivity

Pain can interfere with sleep. But a growing body of literature suggests that lack of sleep or poor quality sleep increases our sensitivity to pain, and that insomnia exacerbates existing pain and predicts new-onset pain.

In a new study, Boston researchers found that sleep deprivation in healthy mice increased their pain sensitivity. The greater the sleep deprivation, the more exaggerated were their responses to pain. After a period of normal sleep, their reaction to pain was much less pronounced.

Then, while still in a state of sleep deprivation, the mice were given caffeine or modafinil (a drug that promotes alertness). Their pain tolerance increased, similar to what they experienced after a full period of normal sleep. So if you’re experiencing pain and trouble sleeping, a caffeinated beverage like coffee may reduce your pain more effectively than drugs prescribed for pain relief.

Reaping the Benefits, Avoiding the Harms

It looks like moderate coffee drinking is associated with better health and resilience to pain. But if you’re prone to insomnia, you’ll need to do a bit of experimenting to find out when and how much you can drink without harming your sleep.

Here are some facts to be aware of as you’re figuring it out:

  • The effects of caffeine vary greatly from one person to the next. This is largely attributable to genetic factors. Drinking coffee later in the day may keep you wakeful and degrade the quality of your sleep, or it may not affect your sleep at all.
  • Research has shown that early risers tend to be the most sensitive to caffeine. People who go to bed and wake up somewhat later have less caffeine sensitivity, and the sleep of night owls may not be affected by caffeine at all.
  • People metabolize caffeine at widely varying rates. The average half life of caffeine (the point at which the amount of caffeine in the blood has decreased by half) is 5 to 6 hours. But the half life of caffeine can vary from 2 to 12 hours. Smokers typically metabolize caffeine quickly; pregnant women, slowly. And we all metabolize caffeine more slowly as we age.

Timing Is Important, Too

When you can safely drink your last cup of coffee may depend in part on the insomnia symptoms you have. For example, I have sleep onset insomnia, or trouble falling asleep at the beginning of the night. I find that drinking coffee after 2 p.m. can keep me wakeful so I avoid coffee later in the day.

But Lesley, who comments on my posts from time to time, has trouble with sleep maintenance insomnia, falling asleep easily at the beginning of the night but waking up in the middle of the night. After successfully working to consolidate her sleep with sleep restriction, she worked out for herself a different coffee drinking routine:

I know I’m pretty caffeine sensitive and for a long time drank only decaffeinated drinks. . . . After reading recent research . . . on caffeine’s effects on sleep and the body clock, I’ve now added caffeine back into my daily routine. I have sleep maintenance insomnia plus an early to bed/early to rise body clock, and I commonly struggle to stay awake in the evenings, and even the late afternoon.

But with much experimentation I’ve found that one instant coffee in the late afternoon and another about 2.5 hours before bedtime helps massively, without affecting me getting to sleep. Of course we’re all different in our tolerance to caffeine, and it’s very much trial and error. But it’s an extremely useful tool to be aware of.

Lesley puts it well: with a bit of trial and error experimentation, we insomniacs may be able to have our coffee and drink it, too.

If you’re a coffee drinker, how does it affect your sleep?

Alzheimer’s Disease: Are You, Poor Sleeper, at Risk?

I talk quite a bit about dementia and Alzheimer’s disease with family and friends. Our parents are drifting into cognitive impairment, asking the same questions again and again and struggling to find words to express themselves, and we wonder if we’re destined for the same fate.

The concern may be justified in middle-aged adults with chronically poor sleep, according to new research on sleep and two proteins involved in Alzheimer’s disease. Here’s more about the study and its relevance to people with insomnia and other sleep disorders.

Proteins linked to Alzheimer's a function of insufficient deep sleepI talk quite a bit about dementia and Alzheimer’s disease with family and friends. Our parents are drifting into cognitive impairment, asking the same questions again and again and struggling to find words to express themselves, and we wonder if we’re destined for the same fate.

The concern may be justified in middle-aged adults with chronically poor sleep, according to new research on sleep and two proteins involved in Alzheimer’s disease. Here’s more about the study and its relevance to people with insomnia and other sleep disorders.

Poor Sleep and Cognitive Impairment

Previous research has shown that poor sleep increases the risk of cognitive impairment. And mild cognitive impairment—trouble thinking and memory loss—is one of the first signs of Alzheimer’s disease. The cognitive declines and memory problems gradually worsen as deposits of two proteins—amyloid beta and tau—grow thicker and thicker, causing brain tissue to atrophy and die. To date the disease is irreversible.

But “poor sleep” can take different shapes and forms:

  • Sleep apnea, or pauses in breathing that occur repeatedly throughout the night, leaving sleepers feeling unrested in the morning.
  • Restless legs syndrome, in which sleep is disrupted by involuntary leg movements in the first half of the night.
  • Insomnia, consisting of trouble falling asleep, staying asleep, or waking up early in the morning, and related daytime complaints

Which feature of some or all of these sleep disorders might hasten development of amyloid plaques in the brain? The researchers suspected the problem had to do with deep, or slow wave, sleep, which is associated with feeling rested and restored in the morning. So they set out to see if disrupted slow wave sleep would bring about increased levels of amyloid beta in the brain.

Who They Studied, What They Did

Seventeen healthy adults ages 35 to 65 participated in the study, none with sleep problems or cognitive impairment. Each participant wore a wrist watch-type device to monitor their sleep. After several nights of wearing the device, participants spent a night in a sleep lab. There, they underwent a sleep study that involved wearing headphones.

Half of the participants were allowed to sleep without interruption. The other half experienced sleep disruption. Every time they entered deep sleep, they were subjected to beeps that grew louder and louder until their slow waves disappeared and were replaced by brain waves characteristic of lighter sleep.

The participants subjected to the beeps reported feeling tired and unrefreshed in the morning although they slept as long as usual. Most did not recall awakening during the night. All participants underwent a spinal tap so researchers could test for levels of amyloid beta and tau in the spinal fluid.

The procedure was repeated a month later, when the participants originally allowed to sleep uninterruptedly were subjected to the beeps and the others were allowed to sleep without interruption. Another spinal tap was conducted in the morning to measure protein levels.

Disrupted Deep Sleep and Harmful Proteins in the Brain

The results supported researchers’ contention about the effects of disrupted slow wave sleep:

  1. Participants’ amyloid beta levels were up by 10 percent after a single night of disrupted slow wave sleep
  2. In addition, levels of tau were significantly higher in participants whose wrist monitors showed they’d slept poorly during the week before the spinal tap

So disrupted slow wave sleep increased amyloid beta levels after just one night and tau levels after several days of poor sleep. Evidently, one function of slow wave sleep is to help rid the brain of byproducts that collect there during the day. When deep sleep is compromised, amyloid beta and tau start to accumulate. Development of cognitive impairment and Alzheimer’s is then more likely to occur.

Alzheimer’s and Poor Sleep in Perspective

So does the overall risk of developing Alzheimer’s increase with every poor night’s sleep? Probably not. Lead author Yo-El S. Ju, cited in a Washington University press release, said it’s unlikely that a single night or even a week of poor sleep has much effect on overall risk of developing Alzheimer’s disease. Amyloid beta and tau levels probably go back down the next time the person has a good night’s sleep, she said.

It’s people with chronic, untreated sleep disorders who should be concerned. Here, too, a dose of perspective is in order. Slow wave sleep occurs during the first half of the night. People who suspect they have sleep apnea, which occurs throughout the night, or restless legs syndrome, which occurs during the first half of the night, would be wise to see a sleep specialist for diagnosis and treatment.

People with chronic insomnia may have cause for concern as well—and maybe not so much. These investigators did not find that excess amyloid beta and tau had anything to do with sleep duration or sleep efficiency. Further, it’s never been shown that the main problem for people with insomnia is insufficient slow wave sleep. Some insomniacs experience a reduced percentage of slow wave sleep. Yet in others, slow wave sleep is intact.

The underlying problem in insomnia may instead involve restless REM sleep, which typically occurs in the second half of the night. It may have nothing to do with the development of amyloid plaques in the brain.

In any event, chronic insomnia can be treated (although the causes remain largely unknown). Click on “insomnia treatment” in the tag cloud to the right for more information.

7 New Insomnia Genes: What’s in It for Us

A flurry of articles recently announced the discovery of seven new risk genes for insomnia. In an era when new genes are being identified for everything from infertility to schizophrenia, you might regard this discovery as simply the soup du jour.

Not me. Growing up when trouble sleeping was attributed to psychological factors, coffee, and alcohol, I was elated by this news. We stand to gain so much from knowing the genetic underpinnings of insomnia.

Causes of insomnia are closer to being figured outA flurry of articles recently announced the discovery of seven new risk genes for insomnia. In an era when new genes are being identified for everything from infertility to schizophrenia, you might regard this discovery as simply the soup du jour.

Not me. Growing up when trouble sleeping was attributed to psychological factors, coffee, and alcohol, I was elated by this news. We stand to gain so much from knowing the genetic underpinnings of insomnia.

A Biological Basis for Insomnia

The most immediate benefit of the discovery is that it affirms what scientists have suspected for years: there is a biological basis for insomnia. This is common knowledge among sleep researchers but not so well known among members of the public or even doctors. They may still blame insomnia on psychological factors and poor self-control and dismiss it as a complaint unworthy of attention or treatment.

“Insomnia is all too often dismissed as being ‘all in your head,’” said Eus Van Someren, a lead researcher on the project, quoted in a press release. “Our research brings a new perspective. Insomnia is also in the genes.”

Genes contain the information needed to make proteins, and proteins do most of the work in the cells in our bodies and brains. The identification of insomnia risk genes suggests that vulnerability to insomnia has a neurobiological basis. It is likely driven by an excess or deficit of key neurochemicals or abnormalities in the circuitry of the brain.

What the Discovery Doesn’t Mean

People sometimes confuse the idea of genetic risk with biological determinism—the belief that hereditary factors are the sole determinants of who we are and the health challenges we face. The assumption is that if constitutional factors predispose a certain disease or health condition, then nothing can be done to alter its course.

There are a small number of irreversible diseases caused by mutations in a single gene. If you’re born with a certain mutation in the HTT gene, for example, you inevitably develop Huntington disease. Nothing can be done to change this.

But most diseases and conditions—insomnia included—are complex. No single gene determines whether you get them or not. Multiple genetic factors likely come into play, increasing the odds of developing a disorder but not making it inevitable. Environmental, social, psychological, and behavioral factors may play as big a role in determining whether you develop insomnia or not.

It might be possible to inherit several insomnia risk genes but, thanks to a privileged set of circumstances, never experience trouble sleeping a day in your life. Likewise, despite being biologically predisposed to experience insomnia, you may be able to manage the disorder some or even most of the time with cognitive and behavioral techniques.

Benefits of Genetic Studies

Genetic studies such as this one will enable scientists to trace the pathways by which insomnia develops and identify the biological mechanisms involved. In turn, insomnia treatments can be developed that alter these particular systems, rather than being aimed at systems merely suspected of involvement. Drugs can be developed to target the root causes of insomnia rather than simply tranquilizing the brain.

Other Discoveries and Implications

  • The insomnia risk genes are known to be associated with disorders that often occur with insomnia: restless legs syndrome, anxiety disorders, depression, and type 2 diabetes. Likewise, insomnia was found to have a shared genetic background with neuroticism and poor sense of well-being, traits that often occur in people with insomnia.
  • Some genetic variants associated with insomnia in women were different from the variants associated with insomnia in men, so the biological mechanisms driving insomnia may in some cases be different. If this is true, insomnia treatments prescribed for women may in some cases need to be different from those prescribed for men.

Every new genetic study brings us closer to the time when trouble sleeping will be treated based on the cause of the insomnia rather than its symptoms. Surely that’s something to celebrate!

Lifelong Insomnia? Don’t Give Up on It Yet

Have you had insomnia all your life? Have your parents said you were a poor sleeper even as a baby?

Trouble sleeping that starts early in life is called idiopathic insomnia. If insomnia is still the black box of sleep disorders, then idiopathic insomnia is the little black box inside the black box.

Here’s what is known about the disorder and options for management.

Lifelong insomnia can be treated by sleep specialist or therapistHave you had insomnia all your life? Have your parents said you were a poor sleeper even as a baby?

Trouble sleeping that starts early in life is called idiopathic insomnia. If insomnia is still the black box of sleep disorders, then idiopathic insomnia is the little black box inside the black box.

Here’s what is known about the disorder and options for management.

What Is Idiopathic Insomnia?

Idiopathic insomnia begins in childhood, sometimes at or soon after birth. Trouble falling or staying asleep or reduced sleep duration is pretty much a nightly affair regardless of situational changes. The disorder is uncommon, affecting less than 1% of the population.

There is no identifiable cause. The presumption is that idiopathic insomnia is driven mainly by biological factors, and at least some of them are probably inherited. Abnormalities in the circadian system or the homeostatic process may be involved and/or there may be a problem in the circuitry controlling sleep and waking in the brain.

A Chronic Sleep Disorder, but How Well Defined?

Idiopathic insomnia is a chronic sleep disorder with familiar insomnia symptoms:

  • Trouble falling or staying asleep, or sleeping long enough, for more than 3 months despite adequate sleep opportunity
  • Daytime distress and impairment, including reduced stamina, low mood, and trouble thinking and learning

Research on the defining features of idiopathic insomnia is mixed. On one hand are a few studies showing significant differences between people with idiopathic insomnia (IdI) and those with psychophysiological insomnia (PI), the garden-variety insomnia that typically develops later in adolescence or adulthood. PI is often triggered by a stressful event; situational factors do not figure in IdI. PI is said to persist mainly due to psychological and behavioral factors that develop in response to poor sleep: conditioned arousal in bed, poor sleep hygiene (going to bed early to catch up on sleep, for example), and anxiety about sleep. Psychological factors are less typical in IdI.

On the other hand is research showing no major differences between PI and IdI when assessed by polysomnography (the overnight test in the sleep lab) or by self-report of psychological symptoms. Research suggests that arousal levels are higher among people with IdI than in people with other kinds of insomnia, though, leading some sleep experts to speculate that IdI is simply a more severe manifestation of PI.

What Can Be Done?

Without scientific certainty about the causes of IdI or whether the disorder is distinct from other kinds of insomnia, IdI is best treated on a case-by-case basis by a sleep specialist. Following are options for treatment.

Especially if a person with IdI has misconceptions and/or anxiety about sleep,

  • Cognitive behavioral therapy for insomnia (CBT-I) may help. CBT-I typically consists of two behavioral components—stimulus control therapy and sleep restriction therapy—and a cognitive component designed to decrease psychological barriers to sleep. Sometimes just changing your attitude about sleep can bring about demonstrable sleep improvements.
  • Acceptance and commitment therapy (ACT) may help. ACT focuses on building mindfulness skills so that, rather than trying to suppress, manage, and control emotional experiences, people develop psychological flexibility and learn to behave in ways that reflect their values and increase well-being. This approach, too, can change the way you feel about sleep and in the process improve your sleep.

If round-the-clock hyperarousal is driving IdI, then therapies designed to decrease arousal may help.

  • Regular, moderate-to-vigorous exercise—activities such as aerobics, calisthenics, biking, running, and weight-lifting—has been shown in recent studies to increase total sleep time and decrease levels of cortisol (a stress hormone).
  • Yoga, too, has been shown to decrease feelings of arousal and promote stress tolerance.

Medication for Idiopathic Insomnia

The issue of sleeping pills for chronic insomnia is increasingly fraught. Many drugs approved for the treatment of insomnia, taken nightly over time, may degrade sleep quality and result in alarming side effects, especially in older adults.

That said, while the medication prescribed for IDI is usually a benzodiazepine or a Z-drug such as zolpidem or eszopiclone, a second pharmacological approach, according to a paper by Michael Perlis and Philip Gehrman, involves use of a melatonin agonist such as ramelteon (Rozerem). No studies of the effects of this sleeping pill on the sleep of adults with IdI have been conducted. But in two studies of children aged 6 to 12 years with chronic idiopathic childhood sleep-onset insomnia, melatonin put them to sleep significantly sooner—by 1 hour.

If you’re contemplating managing lifelong insomnia with drugs, get some professional advice. This is one place where you really need the help of a specialist knowledgeable in the medical treatment of chronic insomnia.

At what age did your trouble sleeping start? What kinds of treatments—if any—have helped?

Herbals for Insomnia? Now You Can Test Them at Home

Herbal remedies for insomnia are abundant online—valerian, hops, and chamomile, among the most common. Tested against placebo, none has been found to be definitively effective for insomnia. Yet some medicinal herbs have a long history as traditional calming, sleep-promoting agents. Might one work for you?

Researchers at Massachusetts General Hospital and Harvard Medical School have proposed a method you can use yourself to test herbal remedies via personalized therapeutic trials. Here’s more about herbals and how the trials work:

Insomnia may respond to treatment with herbal supplements and tincturesHerbal remedies for insomnia are abundant online—valerian, hops, and chamomile, among the most common. Tested against placebo, none has been found to be definitively effective for insomnia. Yet some medicinal herbs have a long history as traditional calming, sleep-promoting agents. Might one work for you?

Researchers at Massachusetts General Hospital and Harvard Medical School have proposed a method you can use yourself to test herbal remedies via personalized therapeutic trials. Here’s more about herbals and how the trials work:

Why Herbals for Sleep?

Interest in herbal and other alternative treatments for insomnia seems to be on the rise. About 5% of the participants in a national survey reported use of complementary and alternative medicine (CAM) for insomnia in 2002. A recent analysis of the same national survey conducted in 2007 found that almost 50% of participants with insomnia symptoms used some form of CAM therapy.

Some insomniacs see alternative medicines as less risky than prescription sleeping pills, with fewer potentially harmful side effects. Because they are “natural,” they’re viewed as more appropriate for long-term use than many sleeping pills, which, if used nightly, tend eventually to degrade sleep quality.

Scant Testing, Mixed Results

Most herbal remedies for sleep have not undergone as much testing as prescription sleeping pills (one reason may be that there’s relatively little money to be made on them). But as with sleeping pills, tests that have been conducted on herbals often show subjective sleep improvements that exceed objective measures.

The perception that herbal supplements improve sleep could be due to a placebo effect. Or, say the Massachusetts researchers, it could be attributable to basic differences among trial participants, including different insomnia symptoms. It could be that, just as a particular sleeping pill works for some insomniacs and not others, a particular herb may relieve insomnia in some people and not others.

Herbals That May Relieve Insomnia

Since the overall efficacy of herbal preparations for insomnia is still unknown and may differ from person to person, the researchers opted to consult six authoritative resources in their search for herbal and supplement remedies of potential relevance for insomnia, including reference books such as the Physician’s Desk Reference for Herbal Medicines (PDR) and online sources such as Medline Plus. In all, they came up with a list of over 70 herbal agents of possible benefit to sleep.

These 15 medicinal herbs were listed by 4 or more resources as a remedy for insomnia or another condition indirectly related to sleep, such as anxiety or nervousness:

  1. Ashwagandha
  2. Bitter Orange (Neroli)
  3. Catnip (Nepeta)
  4. Chamomile (German)
  5. Hops
  6. Kava
  7. Lavender (English)
  8. Lemon Balm
  9. Linden
  10. Nutmeg (and Mace)
  11. Oats (Avena sativa)
  12. Passion Flower
  13. Schisandra (Wu-Wei-Zi)
  14. St. John’s Wort
  15. Valerian

Safety of Herbal Supplements

Natural substances are not necessarily safe for unrestricted use. The PDR for Herbal Medicines cautions against using several during pregnancy. Some herbs may be harmful to the liver. And, as herbal supplements are unregulated in the United States, the contents of a supplement do not necessarily reflect what appears on the label. In fact, a majority of herbal remedies evaluated in a recent study had contamination, substitution, or use of fillers not listed on the label.

For safety concerns associated with herbs used for insomnia, see these sources:

Find Out If a Sedating Herb Works for You

Let’s say you’re a sleep maintenance insomniac, awakening at least twice a night to feelings of anxiety. You’ve heard that passion flower is good for sleep and anxiety, and you’d like to try it to see if it cuts down on your nighttime wake-ups. But how long should you try it? Two nights, three nights or more?

Many insomniacs experience quite a bit of night-to-night variability in their sleep. When you’re stressed out you might sleep poorly for 4 or 5 nights in a row before you get a decent night’s sleep. If you tried taking a passion flower supplement for just 2 or 3 nights during a time of stress, the results you obtained wouldn’t be reliable. You might obtain a different result if you tested the passion flower during a 3-day period when your life was moving along on an even keel.

I’ll skip the authors’ discussion of statistical power and cut to the chase: you need to test a substance for 10 nights in a row to have reasonable certainty that the result you obtain is repeatable and you’ve got enough data to answer the question of whether passion flower improves your sleep.

Self-Testing Flow Chart

Follow these 5 steps to determine whether an herbal insomnia remedy works for you:

  1. Simplify sleep. For you, does “good sleep” mean falling asleep sooner, sleeping longer, waking up feeling more rested, or waking up less at night? Choose the one thing that for you would most improve your sleep.
  2. Set a goal. Choose your target “good night” value and a percentage of nights for which this target value must occur. Let’s say you decide that a good night is a night when you awaken just 1 time or less (and on a bad night you awaken 2 times or more). Let’s say you set your goal at awakening 1 time or less on at least 70% (7 out of 10) of the nights.
  3. Choose a therapy. Try one intervention at a time. Starting a passion flower supplement and a yoga class at the same time will muddle the results.
  4. Do the 10-day test. Every day, record good nights and bad nights in a diary.
  5. Calculate the outcome. Did you achieve your goal? If so, you can conclude that passion flower improves your sleep. If you didn’t achieve your goal, clearly the passion flower did not work. Choose another therapy, starting the process at #3. If your results are borderline, continue testing for another 10 days. Then recalculate to ascertain whether you’ve met your goal of awakening 1 time or less on 70% of all 20 nights.

Insomniacs are big experimenters, I learned as I was conducting research for my book, The Savvy Insomniac. Several expressed interest in herbal and other alternative treatments. If you’re going to experiment, you need a systematic way to assess whether the remedy you’re trying improves your sleep or not. These Massachusetts researchers have given us a goal-oriented algorithm for doing exactly that.

15 Tips for Better Sleep in the Summer

I love warm weather and long summer days. Birds singing, trees leafed out, garden thriving. Me, outside in shorts and a tee-shirt, able to appreciate the natural beauty till almost 10 p.m. What’s not to like?

Insomnia, in a word. On long, hot days I’m just not sleepy at my usual bedtime. I’m up later and later till—oops—I’m in the insomnia trap again.

You’d think I’d know by now: heat and light may boost my spirits but, in too big a dose, they’re a bane to sleep. So now it’s time to knuckle down and observe the rules for better sleep in the summer. Here they are:

Manage insomnia in the summer by cooling off & darkening the house
Here I am planting coleus in the iris bed.

I love warm weather and long summer days. Birds singing, trees leafed out, garden thriving. Me, outside in shorts and a tee-shirt, able to appreciate the natural beauty till almost 10 p.m. What’s not to like?

Insomnia, in a word. On long, hot days I’m just not sleepy at my usual bedtime. I’m up later and later till—oops—I’m in the insomnia trap again.

You’d think I’d know by now: heat and light may boost my spirits but, in too big a dose, they’re a bane to sleep. So now it’s time to knuckle down and observe the rules for better sleep in the summer. Here they are:

Reduce Exposure to Late Evening Light

I love the late evening light but it does not love me. One effect of light on sleep—especially light containing lots of blue light, such as sunlight and the light from devices with screens—is that it blocks release of the hormone melatonin. Melatonin secretion typically starts some two hours before bedtime. Exposure to daylight late in the evening may delay secretion, altering circadian rhythms and keeping us awake later than usual. If you’re light sensitive and looking for insomnia relief,

  1. Wear dark glasses if you’re out for an evening stroll.
  2. Don’t wait until the sun sets to darken your windows. Lower shades and close drapes by 8:30 p.m.
  3. Start your pre-sleep routine at the same time as usual—even if it’s still light outside.
  4. An hour or two before bedtime, get off computers, tablets and and smart phones. Blue-blocker glasses and apps that filter out blue wavelengths are supposed to make light less harmful at night. But I installed f.lux software on my computer and I still think looking at the screen after 9:30 or so has a negative effect on my sleep.

Reduce Exposure to Early Morning Light

Especially if you live at the eastern edge of a time zone, your problem may have to do with the early sunrise at this time of year. Sunlight may start streaming in the bedroom window and wake you up as early as 4:30 a.m. What a lousy start to a summer day! If early awakening is a problem and you’re after insomnia relief,

  1. Invest in a lightweight, light blocking eye mask.
  2. Install light blocking window treatments on bedroom windows and keep them drawn at night.
  3. Consider sleeping in a room with fewer windows around the time of the summer solstice.

Cool Your Bedroom Down in Advance

People with insomnia may have greater temperature sensitivity than good sleepers, or less ability to recognize what a comfortable ambient sleeping temperature is. Summer heat may be the cause of your trouble sleeping now—I know it’s a factor for me. If it feels too hot to sleep,

  1. Keep shades and drapes drawn during the daytime to block out heat from the sun.
  2. If you have air conditioning and want to save on energy during the daytime, turn the thermostat down a degree or two about a half hour before bedtime.
  3. In the absence of air conditioning, use a window fan. But don’t wait till bedtime to turn it on. Keep tabs on the temperature outside and, when it starts to drop, turn on the fan.
  4. If A/C and fans don’t do the trick, try sleeping on a lower level of the house.

Cool Yourself Down

People tend to fall asleep more easily when their core body temperature is falling, which normally it does at night. But research suggests that compared with good sleepers, people with insomnia may have more trouble downregulating internal temperature. If this is true, then especially in the summertime, it’s important to take measures to cool your body down before you go to bed. Research has shown that when done late in the afternoon or early in the evening,

  1. Exercise heats your body up, triggering an internal cooling mechanism that may later help you fall asleep.
  2. You can achieve the same delayed cooling effect by indulging in a warm shower, bath or sauna early in the evening.

But if at 11 p.m. you return to a hot house expecting to take a quick shower and hop into bed, it’s time for emergency measures:

  1. Turn on the A/C and/or fans full blast and take a cool shower.
  2. Place a cool, wet washcloth on your forehead when you finally turn in.

If you have trouble sleeping in the summer, what do you think is the cause of the problem?