Goodbye to Sleep Anxiety (and Fear of Dogs)

Meet Toby, our new dog. No, he doesn’t have a sleep problem. But Toby has a problem that seriously affects the quality of his and our lives: he’s terrified of dogs. We adopted him from a rescue shelter, unaware that the mere sight of a 5-pound Chihuahua would cause Toby to leap and bark as though he feared for his life. Toby’s fear of dogs reminds me of my own fear of sleeplessness, which I struggled with for decades. The problem seemed insurmountable . . . until I went through insomnia treatment and found a way out. If sleep anxiety is your problem too, read on.

Conquering sleep anxiety makes me think I can help Toby overcome his fear of dogs.Meet Toby, our new dog. No, he doesn’t have a sleep problem. But Toby has a problem that seriously affects the quality of his and our lives: he’s terrified of dogs. We adopted him from a rescue shelter, unaware that the mere sight of a 5-pound Chihuahua would cause Toby to leap and bark as though he feared for his life.

Toby’s fear of dogs reminds me of my own fear of sleeplessness, which I struggled with for decades. The problem seemed insurmountable . . . until I went through insomnia treatment and found a way out. If sleep anxiety is your problem too, read on.

Wondering Where the Fear Came From

How our muscular, 47-pound Labrador Retriever mix came to fear even dogs one-eighth his size is something we’ll never know. The shelter had little information about Toby other than that he may have spent some time on a farm.

We do speculate about his past. His fear of dogs might be a symptom of post-traumatic stress. Maybe he was once mauled by a pack of wild dogs (he has no visible marks of mistreatment). Or maybe he simply was not exposed to other dogs during that critical socialization period during puppyhood (the little bit of plaque on his teeth suggests he may now be approaching two years of age).

Regardless of what led to Toby’s fear of dogs, it’s now well entrenched. Yet our trainer says that with proper training we’ll be able to change Toby’s response to and behavior toward dogs.

How My Fear of Sleeplessness Developed

I know more about how my fear of sleeplessness developed (although, memory being as unreliable as it is, here, too, there’s speculation). I think my sleep anxiety must have started with the recognition that I was awake when others in the house/neighborhood/dorm were sleeping, that others seemed to fall asleep more easily and quickly than I did. In fact it was often when I felt exhausted and most craved sleep that I found myself tossing and turning in bed, awake till well after midnight even as a teenager (way before the advent of smart phones!).

Unpleasant symptoms followed those short nights: moodiness and unease during the daytime; at night, tension in the stomach, body warmth, and a racing feeling emanating from my chest down through my arms and legs. It’s no wonder I started worrying about sleeplessness at night: who likes those symptoms, anyway?

Sleep Onset Insomnia and Blaming Myself

Toby can’t see how useless and self-defeating his fear reaction toward dogs is or berate himself for his behavior.

But over the years my anxiety about sleep caused me to feel plenty of anger and disgust with myself. It was bad enough that I had sleep onset insomnia and could never predict when I’d finally fall asleep. But I knew the sensations accompanying my anxiety — the racing mind, the warmth, the tingling arms and legs — were only going to delay sleep further, yet I couldn’t stop myself from feeling them or worrying about how wasted I’d feel the next day.

I tried everything I knew of to solve the problem: relaxation exercises, yoga, tapes featuring sounds of nature, music purported to coax listeners into deep sleep. Those things might work for a week or two but soon I was back to the same old obsessive thinking about sleep. That I was unable to get a grip on the problem, unable to stop myself from prolonging my own wakefulness made me feel like I was engaging in willful self-sabotage. Just how ridiculous was I for doing that?

My fear of sleeplessness felt as entrenched as Toby’s fear of dogs. And it kept me feeling like an adolescent for many, many years. Why couldn’t I grow up and out of this phase and fall asleep like everyone else?

Changing Toby’s Behavior

Apparently changing dogs’ behavior can be accomplished through classical conditioning. Toby is very motivated by food, so we’re doing clicker training with him. Every time he looks at a dog, we click and give him a treat, click and treat, click and treat.

Eventually, the trainer says, Toby will come to associate seeing dogs with the pleasurable experience of eating something tasty rather than the disagreeable thing he experienced before. It’s slow going, but we’re starting to see some changes and we’re only two months into the training.

Overcoming Sleep Anxiety

I went for decades believing I could never turn my fear of sleeplessness around. But it finally happened, and I attribute the change mostly to sleep restriction therapy, an insomnia treatment offered as part of cognitive behavioral therapy for insomnia.

You might think, since my problem involved anxious thinking about sleep, that cognitive therapy would be the way to go. In fact, as I underwent insomnia treatment, I was guided through “cognitive restructuring,” a cognitive approach to extinguishing negative thoughts and feelings about sleep through careful examination and reappraisal. Were my fears about sleeplessness realistic or distorted? If distortion was occurring, what might be an alternative, more balanced way of looking at the situation?

Apparently, this approach to decreasing sleep anxiety works for some people with insomnia. It did nothing for me. My fear of sleeplessness felt far too deeply rooted to be eradicated by simply reasoning with myself.

A Behavioral Approach to Fear Extinction

What it took to finally root out my fear was a behavioral approach similar to the one we’re using with Toby. By restricting my time in bed, sleep restriction therapy created the sleep pressure my brain apparently needed to fall asleep a lot more quickly. I started falling asleep pretty much on cue — a fabulous development! And when I began to see I could count on falling asleep with regularity, my fear of sleeplessness started to fade away.

The process took time, though, just as the process with Toby is going to take time. There were nights when the old anxieties returned to hijack my sleep. But with time the nights when fear ambushed me on the way to the bedroom were fewer and fewer.

Now my fear of sleeplessness is a thing of the past. With persistence and the right kind of insomnia treatment, yours can be made to disappear, too.

If you’ve struggled with sleep anxiety, what have you tried to decrease your anxiety, and has it worked?

Sleep Restriction: New Thoughts on How It Works

Sleep restriction therapy helped me a lot. In fact, even without the other insomnia treatments usually offered with it, sleep restriction alone (enhanced by daily exercise) would probably have turned my chronic insomnia around.

Sleep researchers at Oxford recently proposed a new model of how the therapy works. If you haven’t yet tried sleep restriction, here’s why you’ll want to check it out.

Sleep restriction therapy involves postponing bedtime

Sleep restriction therapy helped me a lot. In fact, even without the other insomnia treatments usually offered with it, sleep restriction alone (enhanced by daily exercise) would probably have turned my chronic insomnia around.

Sleep researchers at Oxford recently proposed a new model of how the therapy works. If you haven’t yet tried sleep restriction, here’s why you’ll want to check it out.

Benefits of Sleep Restriction Therapy

Why would a person with insomnia even consider undergoing sleep restriction therapy (SRT), when what we want is to get more sleep and not less? Well, consider first the benefits. After 4 to 6 weeks of SRT, people typically

  • spend considerably less time in bed awake (a boon to sleep onset and sleep maintenance insomniacs alike)
  • fall asleep about a half hour sooner (particularly helpful for sleep onset insomniacs)

A few studies suggest that by the end of treatment, sleep timing is less variable than before treatment began. Total sleep time may be slightly longer, especially in the young and middle-aged.

If these benefits pale compared with what we really want (one to two hours more sleep, thank you very much!), consider next this new theory of how SRT works.

The Triple-R Model of Sleep Restriction Therapy

Chronic insomnia develops from a mix of physiological, psychological, and behavioral factors, and SRT, the Oxford researchers say, influences all of these factors at once. In effect, SRT walks us back to a time when sleep was less of a problem by doing three main things. It

  1. Restricts time spent awake in bed
  2. Regularizes the timing of sleep and wake
  3. Reconditions the association between bedroom factors and sleep

All together, the Triple-R process produces physiological and cognitive-behavioral alterations which in turn lead to better, healthier sleep.

This new model of SRT is theoretical, describing mechanisms the authors would like to see put to the test. It caught my attention because it pretty well describes what I saw happening when I went through SRT.

Restricting Time in Bed

The concept of restricting time in bed is foreign to many of us with insomnia. To get more sleep, it’s reasonable to think we need to spend more time in bed.

But the minute we find ourselves lying awake in bed for any length of time, we’re on a slippery slope. Lying awake in the darkness, our stamina low and our defenses down, we’re probably not fantasizing about a trip to Hawaii. We’re worrying instead about car payments or a mortgage, we’re obsessing over the latest political crisis. We’re anxious about sleeplessness itself and how it’s going to drag us down the next day.

Thoughts like these trigger physiological arousal—the heart beats faster, the body gets warmer—in turn feeding the mental anxiety, in turn arousing the body still more. Several nights like this can condition bodies and brains to associate the bed not with sleep but rather with wakefulness.

Then we’re cooked: Learned associations like this are hard to unlearn. I tried and failed for over 20 years.

Restricting Time Awake

When I considered sleep restriction, I assumed it would curtail the amount of time I slept. Some curtailment of sleep did occur during the first week of therapy, and that was rough.

But this early stage of SRT didn’t last long. Later the first week, the pressure to sleep increased to a point where by my prescribed bedtime I was falling asleep the minute my head touched the pillow and sleeping right through the night. With improved sleep efficiency, the sleep restriction protocol allowed me to increase my time in bed. So that by the end of therapy what I’d done was not decrease my total sleep time (in fact, I gained about half an hour) but rather decreased my time awake in bed.

What’s not to like about that?

Regularizing the Timing of Sleep and Wake

Regularity may sound boring but looking back, I think my insomnia was one of many signs my body actually craved it. And SRT delivered on that score. Starting from the first week of treatment I had to adhere to the same sleep schedule for one entire week. I made small adjustments on a weekly basis only, according to the protocol, adding time in bed as my sleep became more robust.

Why was regularity so important? Sleep and wake are controlled by two internal forces, the circadian pacemaker (the body clock) and the homeostatic pressure to sleep. Together, they dictate when we feel sleepy and when we feel alert. An erratic sleep schedule will tend to push these forces out of alignment, setting up the conditions for persistent insomnia.

A regular sleep schedule helps these forces remain in sync, in turn promoting better sleep. In myself, what I’ve observed is that regularity in almost everything I experience on a daily basis, including meals, exercise, light exposure, and even socializing, seems to benefit my sleep.

Reconditioning Myself for Sleep

Once sleep became more predictable, and once I was mainly sleeping when I was in bed (rather than lying in bed awake), my anxieties about sleep began to fade. Fear of sleeplessness wasn’t so quick to ambush me en route to the bedroom or when I glimpsed the clock at 2 a.m.

This last step in process — replacing my expectation that I’d be wakeful in bed with the expectation that I would sleep — came about gradually. During a couple of insomnia flare-ups, I needed to restrict my sleep again to keep my recovery on course.

But by the end of the first year post-SRT, my anxieties about sleep were pretty much a thing of the past. And that is truer now than it was 10 years ago. I’ve stuck with the habits I developed in SRT, and my sleep is much more robust as a result.

SRT is not a magic bullet, but by my lights it’s the most effective insomnia treatment available today. Anyone with chronic insomnia will want to check it out.

Vitamin D for Better Sleep?

Seasonal insomnia typically strikes at about this time of year. As the days get shorter, we’re exposed to shorter periods of sunlight, which can alter circadian rhythms and interfere with sleep.

A related problem has to do with our need for vitamin D, which may not be met in low sunlight conditions. Recent publications explore the effects of low levels of vitamin D on sleep, making supplements a good option in the cold weather.

Seasonal insomnia may be driven by vitamin D deficiencySeasonal insomnia typically strikes at about this time of year. As the days get shorter, we’re exposed to shorter periods of sunlight, which can alter circadian rhythms and interfere with sleep.

A related problem has to do with our need for vitamin D, which may not be met in low sunlight conditions. Recent publications explore the effects of low levels of vitamin D on sleep, making supplements a good option in the cold weather.

A Relationship Between Sleep and Vitamin D

It’s well established now that lack of exposure to sunlight has a negative effect on sleep. Interest in the relationship of vitamin D to sleep is relatively new, yet preliminary evidence suggests that low levels of D are associated with short sleep duration, a frequent complaint of people with insomnia. A recent meta-analysis of studies of vitamin D deficiency and sleep disorders also found an association between low levels of D and poor sleep quality.

Levels of vitamin D fluctuate seasonally. Our bodies make most of the vitamin D we need when our skin is exposed to sunlight, and typically there are fewer opportunities for sunlight exposure in the colder months of the year. Thus insufficient vitamin D could be a factor in seasonal insomnia.

Vitamin D Supplements: Will They Improve Sleep?

While a few studies document improved sleep as a result of higher levels of vitamin D, a causal relationship between vitamin D supplementation and better sleep has not been definitively established. However, for a host of health reasons including sleep — avoidance of infectious, autoimmune and neurological diseases, as well as neuromuscular disorders and increased pain sensitivity — vitamin D deficiency is a condition we should try to avoid.

It’s a good idea to pay attention to recommended dietary allowances — expressed in international units (IU) per day — especially in the wintertime. They were established by the Institute of Medicine based on vitamin D’s importance to the development and maintenance of healthy bones. Subsequently the Endocrine Society established recommended dietary allowances for people at risk for vitamin D deficiency. Here’s a table showing both sets of guidelines for daily intake of vitamin D:

Infants Ages 1–18 years Ages 19–70 years Ages 71 & older
Institute of Medicine 400 IU/day 600 IU/day 600 IU/day 800 IU/day
Endocrine Society 400-1000 IU/day 600-1000 IU/day 1500-2000 IU/day 1500-2000 IU/day

Foods Containing Vitamin D

Up to 80% of our D requirement may come from the complex metabolic processes triggered with exposure of the skin to sunlight. But we also get vitamin D from a limited number of foods. Some foods naturally contain D and other foods are fortified with it. Here are some common foods containing vitamin D and approximate amounts:

  • 3.5 oz salmon, fresh (wild): 600–1,000 IU
  • 3.5 oz salmon, fresh (farmed): 100–250 IU
  • 3.5 oz salmon, canned: 300–600 IU
  • 3.5 oz sardines, canned: 300 IU
  • 3.5 oz mackerel, canned: 250 IU
  • 3.5 oz tuna, canned: 236 IU
  • 3.5 oz shiitake mushrooms: 100 IU
  • 1 egg yolk: 20 IU
  • 3.5 oz beef liver, braised: 12–30 IU
  • 8 oz fortified milk or yogurt: 100 IU
  • 8 oz fortified orange juice: 100 IU
  • 3 oz fortified cheese: 100 IU

Breakfast cereals and soy products are also often fortified with vitamin D.

At Risk for Vitamin D Deficiency

You’re more likely to have low levels of vitamin D in these conditions:

  • You get little exposure to sunlight. This may occur if you live in a northerly latitude, spend all or most of your time indoors, habitually wear clothing covering your entire body or cover up with sunscreen all the time. (An SPF of 30 or higher, which confers important protection from cancer, decreases vitamin D synthesis in the skin by more than 95%.)
  • You have dark skin. Dark skin confers natural protection from harmful radiation from the sun but also makes it harder to synthesize vitamin D. Longer periods of sun exposure are required for sufficient vitamin D production to occur.
  • You’re vegan. Most natural sources of vitamin D are animal based.
  • You’re obese. Individuals with a body mass index of 30 or higher often have low blood levels of vitamin D.
  • You’re pregnant or lactating. Pregnant and lactating women may have decreased levels of vitamin D as well.
  • You’re older and have a history of falls and/or fractures. Older adults are somewhat less efficient at synthesizing vitamin D via sunlight exposure.

Vitamin D Supplementation

To remedy low levels of vitamin D, or to maintain adequate levels throughout the winter, take a vitamin D supplement. Take your daily supplement with a meal containing fat, as this will increase vitamin D absorption.

Supplementation and adequate exposure to sunlight (or bright light supplied by a light box) at the approach of the holidays and through the winter may help to protect you from the bane of seasonal insomnia.

CBT for Insomnia: Where to Find the Help You Need

Here’s a question that often comes my way: “I’d like to try cognitive behavioral therapy for insomnia [CBT-I], so where can I find a sleep therapist?”

The availability of CBT-I providers varies depending on where you live. Here’s where you’re likely to find help and where you’re not, and alternative ways to get the insomnia treatment you’re looking for.

Where to find a therapist who does CBT for insomniaHere’s a question that often comes my way: “I’d like to try cognitive behavioral therapy for insomnia [CBT-I], so where can I find a sleep therapist?”

The availability of CBT-I providers varies depending on where you live. Here’s where you’re likely to find help and where you’re not, and alternative ways to get the insomnia treatment you’re looking for.

Why CBT for Insomnia?

It’s the most effective insomnia treatment known at this time, improving sleep for 70 to 80 percent of the people who try it. CBT-I is more effective and long lasting than treatment with sleeping pills, and it’s effective for many people with chronic insomnia who also have other health problems such as depression, anxiety, or sleep apnea.

For more information on CBT-I, take a quick look at this blog post I wrote at the beginning of last year.

Where Can I Find Treatment?

It depends on where you live, say authors of a paper published last year in Behavioral Sleep Medicine. If you live in New York or California, insomnia therapy is likely close at hand. If you live in Hawaii, South Dakota, Wyoming, or New Hampshire, you’ll have no luck in finding a doctor, psychologist, or nurse practitioner trained in behavioral sleep medicine. Authors of the paper were unable to find a single provider practicing in those states.*

Here’s a chart showing the number of behavioral sleep medicine providers in the US by state:

No. of providers States
73–33 CA, NY, PA, IL, MA, TX
27–22 FL, OH, CO, MN, MI, WA
17–10 MD, NC, TN, AZ, MO, DC
9–6 CT, VA, WI, AL, OR, AR, SC, WV, IN, ME, NJ
5–3 AK, DE, GA, KS, LA, NE, RI, KY, NM, NV, OK, UT, MS
2–0 ID, ND, IA, MT, VT, HI, NH, SD, WY

 

Canada has 37 behavioral sleep medicine providers, but no other country outside the US has more than 7.

Do I Really Need a Sleep Therapist for CBT-I?

There are alternatives to working with a doctor or therapist trained in behavioral sleep medicine. But working with a professional—someone with a clear grasp of the protocol who can lead you through it step by step, motivating you to continue if the going gets rough—is probably the best way to ensure success and maximize the gains you’re going to make.

“Having somebody who’s experienced with this telling me that, if I do this, there’s a good chance everything will turn around is very inspiring,” said a man I interviewed for my book, The Savvy Insomniac, after we finished a group course in CBT-I.

Find a professional trained to administer CBT-I by clicking on this provider directory.

What If I Can’t Get Insomnia Therapy Nearby?

Your next best bet is to take an online course in CBT-I. These interactive courses have been found to be as effective as the face-to-face coaching you’d receive from a sleep therapist, the only downside being that research shows people going through an online course are more likely to drop out. Check these programs out:

  • CBT for insomnia is a 5-week course developed by sleep specialist Gregg D. Jacobs at Harvard Medical School. The cost is $49.95.
  • SHUTi sells its 6-week course, developed by Canadian sleep specialist Charles Morin, for $149. The price includes access to the site for 26 weeks. The extended access might appeal to you if (1) you’re not ready to jump right into the course, (2) something unforeseen happens during therapy and you have to start all over again, or (3) you feel you might like to continue tracking your sleep after the course ends.
  • Sleepio, developed by UK sleep specialist Colin Espie, offers a 6-week course plus a year’s access to the website and a host of supplementary materials for the hefty price of $400. What you’d gain from a whole year’s access to the website isn’t clear to me. But you may be able to access Sleepio for free by agreeing to take part in a research study.

Couldn’t I Just Read a Book?

You could. Stephanie Silberman’s book, The Insomnia Workbook: A Comprehensive Guide to Getting the Sleep You Need, leads you step by step through everything you need to know to go through CBT-I using the book as your guide. But here’s a warning: while I know it’s possible to succeed in self-administering CBT-I using only a book as a guide (I did), I hear some people complain of failure. Make sure you succeed by starting out right:

  1. Read all you can about the CBT-I protocol before starting therapy. It’s important to understand the process before you begin.
  2. For 1 to 2 weeks before you start therapy, keep a sleep diary (download a sleep diary here), recording bed and rise times and relevant habitual activities.
  3. From the data you’ve gathered, calculate your average nightly total sleep time and set your initial sleep window accordingly. (But if you sleep less than 5 hours a night, set your sleep window at 5 hours.)

Stick closely to the protocol and hang tight. Your sleep should start to improve in a couple of weeks.

If you’ve found this blog post helpful, please like and share on social media. Thanks!

*To gather data, the authors consulted a directory of professionals certified in behavioral sleep medicine, BSM provider lists, and BSM listservs.

Sleep Onset Insomnia: 8 Do’s and Don’ts for Better Sleep

Sleep-onset insomnia—trouble falling asleep at the beginning of the night—has been one of the biggest challenges in my life. By now, having gone through insomnia therapy and spent decades observing how changes in behavior and the environment affect my sleep, I know what I need to do—and what not to do—to get the best night’s sleep I can.

If you’ve got sleep-onset insomnia, here are 8 do’s and don’ts that may help to regularize your sleep.

Sleep-Onset Insomnia can be minimized by changing habitsSleep onset insomnia—trouble falling asleep at the beginning of the night—has been one of the biggest challenges in my life. By now, having gone through insomnia therapy and spent decades observing how changes in behavior and the environment affect my sleep, I know what I need to do—and what not to do—to get the best night’s sleep I can.

If you’ve got sleep onset insomnia, here are 8 do’s and don’ts that may help to regularize your sleep.

Do These Things to Fall Asleep Faster:

  • Get up at the same time every day, including on weekends. This one of the hardest—but most important—habits to adopt, and frankly it’s one I struggle with to this day. Especially after a late night or two, it’s hard to stay the course and get up at 6 a.m. But if I don’t stick pretty rigidly to what I’ve decided is the best rise time for me, if I allow myself more than a little flexibility, my sleep goes off the rails. Making up lost sleep at the beginning of the night, rather than at the end, is by far the easier course.
  • Sign off all devices with screens at least an hour before you usually go to bed—and that includes eReaders and smartphones. If you’re a news junkie like me, watching out for headlines so you can read new stories the minute they come out, this can feel like major deprivation. Yet the light emitted by these screens has been shown time and again to interfere with melatonin secretion, delaying sleep onset—exactly what none of us wants.
  • Get regular exercise and eat regular meals. Aerobic exercise late in the afternoon works best for me, and adhering to my daily workout routine has become so ingrained that when I miss my exercise fix my body doesn’t feel like winding down at night. Regular exercise and regular meals—in fact, regularity in almost all activities because it helps regularize internal circadian rhythms—will likely help you sleep better.
  • Pay attention to the temperature of your bedroom and make adjustments early if necessary. The ideal temperature for sleep is a few degrees lower than what you’re comfortable with during the daytime. So, particularly as research suggests that people with insomnia may have trouble down-regulating internal body temperature, get the window fan going well before bedtime so that by the time it comes you’re not too hot to sleep.

Don’t Do Things That Perpetuate Trouble Falling Asleep:

  • Don’t watch the clock at night. Nothing triggers my anxiety about sleep as much as glancing at the clock at, say, 1 a.m. and realizing I’m not sleepy yet. This is one association—between the clock registering time late at night and trouble sleeping—that I’ve never gotten rid of despite my improved sleep. Turning my clocks toward the wall after about 10 p.m. solves the problem, and it might help you sleep better, too.
  • Don’t jump in bed the minute you get home even if you get home late. For me, heading to bed right away gives my brain permission to trot out all the unfinished business of the day and chew on it while I toss and turn in bed. If you get home late, put on your pajamas, brush your teeth and so forth. But then take 20 or 30 minutes to unwind—read a book or listen to music—before you hit the sack.
  • Don’t stay in bed if, after 15 or 20 minutes, you find you can’t sleep. For me, remaining in bed almost always results in continuing wakefulness, exactly the opposite of what I want. Instead, get up and do some quiet, low-stimulation activity—page through catalogs, make a travel list, cull your bookshelves—until you feel sleepy. Then head back to bed.
  • Don’t beat yourself up—when you’ve adopted all the sleep-friendly habits you possibly can—if you’re still feeling wakeful when your normal bedtime comes around. There’s a genetic component to insomnia, and there are genetic factors that determine sleep onset latency. One day, it may be possible to alter gene expression and so improve sleep. For now, acceptance of the occasional bad night is something it pays all of us to learn to do.

If sleep onset insomnia is your problem, what behaviors seem to make it worse and which behaviors, if any, seem to help?

Anxiety About Sleep: Could Herbal Medicines Help?

“I have 5 years of anxiety about not being able to sleep to overcome,” began a query I received a month ago. “Once triggered, it is difficult to stop this downward spiral and sleep.”

Without a doubt, anxiety about sleep is one of the hardest aspects of insomnia to beat. Cognitive behavioral therapy for insomnia can help to reduce sleep-related anxiety, as can other adjunctive therapies. But here’s an alternative treatment that might lead to calmer nights: plant-based medicines found to be effective for anxiety.

Insomnia-driven sleep anxiety & herbal medicines“I have 5 years of anxiety about not being able to sleep to overcome,” began a query I received a month ago. “Once triggered, it is difficult to stop this downward spiral and sleep.”

Without a doubt, anxiety about sleep is one of the hardest aspects of insomnia to beat. Cognitive behavioral therapy for insomnia can help to reduce sleep-related anxiety, as can other adjunctive therapies. But here’s an alternative treatment that might lead to calmer nights: plant-based medicines found to be effective for anxiety.

Anxiety About Sleep: How It Develops

Anxiety about sleep is learned, and the learning is largely unconscious. The anxiety may develop during a stressful situation when you’re having trouble with sleep. You might be in a tight spot at work or in the midst of a contentious divorce. You might be worried about a new breast lump or how to make ends meet for the next 6 months.

Whatever the stress, it keeps you up at night and soon it extends to worry about sleep itself. What happens if you can’t get enough sleep? What if you’re too sleep deprived to meet the next work deadline? What negative effects will insomnia have on your long-term health?

Once anxiety becomes focused on sleep, it’s hard to root out. The triggers may remain unknown: a darkening sky, evening birdsong, the bed itself. A simple glance at the clock can set off alarms in your head. (“It’s already midnight and I’m still too wired to sleep!”) And feelings of anxiety — muscle tension, a rapid heartbeat, bodily warmth and perspiration — can sabotage sleep. If night after night this pattern is reinforced, no wonder it’s hard to break.

Herbal Remedies for Anxiety

Anxiety about sleep is situational, and therapies shown in clinical trials to lower sleep-related anxiety — cognitive behavioral therapy for insomnia (CBT-I), yoga, and mindful stress reduction — are probably the most reliable paths to relief. Exercise has stress-reducing effects as well. But GABA is the neurotransmitter most prominently associated with calming the brain, and plant-based medicines that act on the GABA system may be helpful, too.

A team of Australian researchers recently conducted a systematic review of plant-based medicines for anxiety including both clinical (human) and preclinical (in vitro and animal) studies. Following are herbal medicines the evidence shows are mostly likely to have anxiety-reducing effects.

Kava (Piper methysticum)

Kava, native to the South Pacific, is the hands-down winner when it comes to the amount of evidence amassed in support of its effectiveness as an herbal remedy for anxiety. “The number of positive findings from human studies of P. methysticum within randomised, well-controlled trials . . . supports its use as a treatment for various anxiety disorders and associated symptoms, demonstrating broad clinical utility,” the authors write.

The main active ingredients in kava are called kavalactones. Kava supplements contain specific concentrations of these kava extracts and are available in tablet form or as a tincture. See my earlier blog post for an in-depth treatment of kava’s effects on anxiety and sleep and possible adverse effects.

Valerian (Valeriana officinalis)

Valerian, native mainly to Europe, looks like the next most-promising herbal with anxiety-reducing properties. The root extract has been used as a sedative and anti-anxiety medicine for millennia. Tests on human subjects have found that valerian is particularly effective at reducing subjective feelings of anxiety that arise in stressful situations.

Two human studies suggest that valerian doesn’t negatively impact psychomotor and cognitive performance the way the benzodiazepines (medications often prescribed to reduce anxiety) tend to do. So regarding safety, valerian has a relatively clean bill of health.

Passion flower (Passiflora incarnata)

Passion flower, native to the Americas, has been used for millennia as an herbal remedy for anxiety and trouble sleeping. Investigators in 4 clinical trials studied its anxiety-reducing effects in patients who were about to undergo surgery. Results showed that passion flower significantly reduced anxiety in comparison with placebo. In fact, its effects were similar to those of anti-anxiety benzodiazepine medications, including, in one of the studies, reductions in blood pressure and heart rate.

Two more studies involving use of passion flower in people with anxiety disorders showed the herb’s anti-anxiety effects were similar to those produced by benzodiazepines.

Ashwagandha (Withania somnifera)

Ashwagandha, traditionally used in Indian Ayurvedic medicine, is a plant in the nightshade family. (It’s sometimes called Indian ginseng.) Ashwagandha powder, prepared from the root, leaves, or whole plant and taken orally, has been prescribed to reduce anxiety and improve sleep for centuries. Today it’s available as a dietary supplement in powder, capsule, and tablet forms.

In 5 clinical trials, ashwagandha was found to have at least one significant anti-anxiety, anti-stress benefit compared with control conditions. Another very recent clinical trial involving participants with chronic stress compared the use of 600 mg of ashwagandha extract daily to placebo capsules taken over 8 weeks. Significantly greater stress reduction occurred with the extract, as did decreases in salivary cortisol (a biomarker of stress and anxiety). See my earlier blog post for more information on ashwagandha’s effects on stress, anxiety, and sleep.

Chamomile (Matricaria recutita)

Chamomile, a flowering plant in the daisy family, is plentiful throughout Europe and Asia. It’s been used for millennia, mainly as a tea, for its calming and sedative effects. In an 8-week clinical trial in patients with generalized anxiety disorder (GAD), participants taking 220 mg of chamomile 1 to 4 times daily showed significantly greater reductions in anxiety than controls. In another 8-week study involving patients with GAD taking a 500-mg capsule of chamomile 3 times a day, 58% of the participants showed significant reductions in anxiety.

In a strange twist, a study of the effects of chamomile in 34 patients with insomnia found that chamomile was effective at improving sleep and daytime stamina but did not reduce symptoms of anxiety.

Final Caveat

If you plan to try herbal medicine as an alternative treatment for anxiety about sleep, consult a naturopath or other health professional about the correct dose. At least do some research yourself.

And don’t expect momentary relief. Herbal medicines, said Jerome Sarris, an author of the Australian review paper whom I also interviewed for The Savvy Insomniac, “generally take longer to work, whereas some people just want that quick fix. I think they may have more of a role in long-term assistance.” So use herbal medicines as indicated and wait at least a few weeks to start looking for results.

Don’t Let Insomnia Spoil the Summer

Do you experience a sudden onset of insomnia at about this time every year? Not much is written on seasonal insomnia that occurs in warm weather. Yet I’m convinced it’s a real phenomenon since my posts on summer insomnia get lots of traffic starting in May.

Here’s updated information—and speculation—on what could be causing the problem and how to get a better night’s sleep.

Waking up too early caused by bright summer sunriseDo you experience a sudden onset of insomnia at about this time every year? Not much is written on seasonal insomnia that occurs in warm weather. Yet I’m convinced it’s a real phenomenon since my posts on summer insomnia get lots of traffic starting in May.

Here’s updated information—and speculation—on what could be causing the problem and how to get a better night’s sleep.

Excessive Heat and Light

Late spring and summer are the hottest, lightest times of the year, and excessive heat and light are not very conducive to sleep.

In humans, core body temperature fluctuates by about 1.5 degrees Fahrenheit every day. Sleep is most likely to occur when core body temperature is falling (at night) and at its low point (some two hours before you typically wake up). Some research suggests that impaired thermoregulation may be a factor in insomnia, that sometimes you may simply be too hot to fall asleep. If so, a bedroom that’s too hot may exacerbate that problem, interfering with your body’s ability to cool down.

Light, too, can interfere with sleep. It does so by blocking secretion of melatonin, a hormone typically secreted at night. Exposure to bright light late in the evening or early in the morning—a phenomenon more likely to occur in months around the summer solstice—may keep you from sleeping as long as you’d like.

Other Possible Challenges to Sleep in the Summer

Swedish researchers have found that people with environmental intolerances to things like noise and pungent chemicals are more prone to insomnia than people without these intolerances. Depending on where you live, sleeping with open windows in the warm weather—if it leads to more noise or bad odors in the bedroom—could interfere with sleep.

Finally, new research conducted at Poznan University of Medical Sciences found that medical students in Poland had higher levels of circulating cortisol—a stress hormone—in the summer than in the winter. This is a preliminary result, and whether it can be confirmed or will hold true for the general population is unknown. Yet if humans do have higher levels of cortisol in the summer than in the winter, this, too, could have a negative effect on sleep.

Sleep Better in the Hot Weather

Climate control is the answer to many environmental triggers of insomnia in the spring and summer. Yet not everyone has air conditioning. If at night you’re too hot to sleep, take care to cool your sleeping quarters down in advance:

  • In the daytime, keep window shades and curtains closed to block out heat from the sun.
  • Later in the evening, use a window fan (facing outward) to draw cool air through the house. Open and close windows strategically so the bedroom is cool by the time you’re ready to sleep.
  • If your bedroom is on an upper floor that simply won’t cool down, sleep on a makeshift bed downstairs.

If keeping windows open at night exposes you to too much outside noise, block it out with silicone ear plugs or high-tech ear plugs, or mask it with white or pink noise using a small fan, a white noise machine, or SleepPhones.

Manage Your Exposure to Sunlight

Daily exposure to bright light helps keep sleep regular—but not if the exposure comes early in the morning or at night. Sunlight that awakens you at 5 a.m. or keeps you up past your normal bedtime may shorten your summer nights, depriving you of the full amount of sleep you need. If you’re sensitive to light,

  • Install light-blocking shades, curtains, and skylight covers on bedroom windows.
  • Purchase a lightweight eye mask for use during sleep.
  • Wear sunglasses if you’re outside in the evening.
  • At home, lower shades and curtains by 8:30 or 9 p.m. even if it’s still light outside, and start your bedtime routine at the same time as you do in other seasons.
  • Avoid devices with a screens in the hour leading up to bedtime.

Reduce Stress

If circulating stress hormones are an issue during the summertime (or if for any reason you’re feeling stress), then kicking back and relaxing, typical in the summer, is not necessarily going to be a dependable path to sound sleep. To reduce stress and sleep better, find a way to make regular aerobic exercise part of your day despite the heat:

  • Do the outdoor sport of your choice—walking, jogging, bicycling—early in the morning or early in the evening. Mall-walking may not be very sexy, but it sure beats walking in 100-degree heat.
  • Buy a seasonal membership in a gym or recreation center, where you can work out in air conditioning.
  • Take up swimming.

A woman recently wrote me wondering if the allergies she normally experiences late in April could trigger seasonal insomnia. I couldn’t find any information on this. But insomnia that routinely occurs at certain times of year is probably triggered by environmental or situational factors. Figuring out what the triggers are is the first step to finding a remedy.

Off-Label Prescribing for Insomnia: What to Expect

Several drugs approved for insomnia are in the doghouse these days, and physicians are doing a fair amount of off-label prescribing. What medications should we expect to be prescribed in lieu of zolpidem (Ambien) and temazepam (Restoril)?

Using a “translational approach,” McGill University researchers have reviewed a host of medications with sedative properties and found the evidence base for some is stronger than for others. Here are the drugs they’ve found are most likely to work.

Insomnia treated with sleeping pill substituteSeveral drugs approved for insomnia are in the doghouse these days, and physicians are doing a fair amount of off-label prescribing. What medications should we expect to be prescribed in lieu of zolpidem (Ambien) and temazepam (Restoril)?

Using a “translational approach,” McGill University researchers have reviewed a host of medications with sedative properties and found the evidence base for some is stronger than for others. Here are the drugs they’ve found are most likely to work.

Why Not Stick With the Tried and True?

Z-drugs such as zolpidem and benzodiazepines such as temazepam may be fine for short-term or occasional use. But lots of people who take these sleeping pills go on to become chronic users.

This can cause problems. People who take a Z-drug or a benzodiazepine nightly for months and years often experience adverse effects: a decrease in deep (or slow-wave) sleep and/or cognitive and motor impairments the next day. Some develop drug dependency.

The Off-Label Prescribing Dilemma

So where’s the next generation of sleeping pills in line to replace the ones we’re using now? A few new drugs are in the pipeline, but none I’m aware of are going up for FDA approval soon. As often happens, we’ve got to fall back on drugs already approved to treat other health problems. It’s perfectly legal for doctors to prescribe such drugs off label as treatment for insomnia.

The problem lies in knowing which other drug(s) to choose. Medications approved for insomnia have demonstrated their efficacy in at least two randomized clinical trials (RCTs) conducted on people with insomnia (and no other related condition). Compared with placebo, they’ve been found to significantly improve sleep. Medications approved for other health conditions—such as depression, anxiety, or neuropathic pain—may have known sedative properties. But in many cases they haven’t been tested for efficacy on people with simple insomnia.

A Translational Approach

In an in-depth review paper published this month in Pharmacological Reviews, the McGill University researchers propose instead using a translational approach to evaluate these drugs for efficacy in treating insomnia. This involves integrating what basic scientific research has shown about a drug’s pharmacology and mechanism of action with clinical data and current medical practice.

Using this approach, the researchers went on to identify medications most likely to serve as effective alternatives for Z-drugs and benzodiazepines. Here they are:

Drugs That Act on the Melatonin System

1. Prolonged-release melatonin (PRM): FDA-approved dietary supplement sold over the counter in the United States; sold as a prescription drug (2 mg/day) in Europe. “Good evidence,” based on 4 RCTs, that PRM is effective for insomnia disorder in adults over age 55 (particularly in reducing time to sleep onset). There’s no evidence that PRM is effective for younger adults with insomnia. (Caveat: The quality control of dietary supplements sold in the United States is not nearly as reliable as the control of prescription medications. Your physician may be able to steer you toward a reliable brand.)

2. Ramelteon (Rozerem): FDA-approved drug for treatment of sleep onset insomnia. “Strong evidence,” based on 2 meta-analyses, that the drug reduces subjective time it takes to fall asleep but no evidence that it helps people sleep longer.

3. Agomelatine (Melitor): Not available in the United States but approved for treatment of major depressive disorder in Canada and Europe. “Good evidence,” based on 1 review and 2 RCTs, that this drug reduces sleep latency in people with depression. Unlikely to improve sleep in people with simple insomnia.

A Drug That Acts on the Orexin System

4. Suvorexant (Belsomra): FDA-approved drug for treatment of insomnia disorder. “Strong evidence,” based on 2 systematic reviews, that the drug reduces insomnia symptoms at doses of 15 mg and higher. It purportedly increases total subjective sleep time and decreases subjective time to sleep onset. (Caveat: Because this drug is a relative newcomer, less is known about its real-world effectiveness and actual side effects. For more information, read my earlier post about Belsomra and take a look at the reader comments.)

Sedating Antidepressants

5. Low-dose doxepin (Silenor): FDA-approved drug for treatment of sleep maintenance insomnia that acts on the histamine system. “Strong evidence,” based on 1 systematic review, that this drug enhances sleep maintenance by reducing nighttime wake-ups. It has not been found to cut down on time to sleep onset.

6. Trazodone: FDA-approved drug for treatment of depression. At low doses, commonly prescribed off label for treatment of insomnia. It acts on the histamine, serotonin, and catecholamine systems. “Good evidence,” based on 2 RCTs, that trazodone reduces insomnia symptoms in people who are taking selective serotonin reuptake inhibitors (SSRIs) to manage depression. This is the only conclusion drawn by the McGill researchers about trazodone. It does not account for the drug’s great popularity with physician prescribers, who for decades have been prescribing trazodone for insomnia rather than Z-drugs and benzodiazepines.

More on Trazodone

So I looked at another paper, this one a systematic review of trazodone for insomnia published in Innovations in Clinical Neuroscience in August 2017. From a pool of 45 studies (the inclusion criteria were evidently less stringent for these researchers than for the McGill researchers, who reviewed 16 studies of trazodone), the second team of researchers concluded that trazodone “is a generally safe therapeutic that has been repeatedly validated as an efficacious treatment for insomnia, particularly for patients with comorbid depression,” with some evidence that it decreases sleep latency, increases sleep duration, and improves sleep quality. Side effects, which may show up in people taking doses higher than 100 mg, include daytime sleepiness, headache, and hypotension, increasing the risk of falls.

The evidence base for trazodone’s effectiveness as a drug for people with simple insomnia is sparse yet suggestive of similar benefits, the second research team reports. (Results of a recent 6-week clinical trial comparing 3 active insomnia treatments—behavioral therapy, zolpidem, and trazodone—are not yet available. Stay tuned.)

An Anticonvulsant Drug

7. Pregabalin: FDA-approved drug for treatment of neuropathic pain, seizures, and fibromyalgia. There is “good evidence,” based on 2 review papers, that pregabalin is effective in reducing symptoms of insomnia in generalized anxiety disorder. There is also “good evidence,” based on 1 review, that the drug is effective in reducing symptoms of insomnia in fibromyalgia. But no evidence base for pregabalin as a treatment for simple insomnia exists.

The medical treatment of insomnia has always been problematic, even more so in the past than today. While your physician may be reluctant to keep writing prescriptions for zolpidem, other, possibly safer medications may be available when behavioral treatments for insomnia don’t suffice.