Insomnia? Acupuncture May Be Worth a Bid

A live-in personal assistant named August, an insomnia sufferer I interviewed for my book, was convinced that acupuncture was the path to better sleep. One day he took his insomnia to an acupuncturist trained in China. After that, he was hooked.

Insomnia may respond to treatment with acupunctureA live-in personal assistant named August, an insomnia sufferer I interviewed for my book, was convinced that acupuncture was the path to better sleep. He was an anxious sort of guy whose work was somewhat unstable, and I wouldn’t have pegged him as a person who’d be drawn to alternative treatments like acupuncture. But one day he took his insomnia to an acupuncturist trained in China and, after that, he was hooked.

“It’s very relaxing,” August said. “It’s the closest thing to magic I’ve ever seen. With acupuncture, I fall asleep easier and sleep longer.”

Acupuncture Research

Studies of acupuncture as a treatment for insomnia have produced mixed results. Some have found that it improves sleep quality while others have not. A survey of medical literature through 2011 concludes that there’s not enough high-quality evidence either to support or refute acupuncture as a treatment for insomnia.

But two very recent studies are encouraging.

  • Postmenopausal women in Brazil underwent a series of 10 acupuncture treatments over a period of five weeks. Compared to a similar group of women who underwent a “sham” treatment, the acupuncture subjects reported significantly improved sleep quality and said they felt better during the day. Polysomnogram testing showed that by the end of treatment, the acupuncture group was getting a higher percentage of deep sleep than the sham group.
  • Researchers in Taiwan found that the sleep quality of insomniacs treated with acupuncture once a week for four weeks improved significantly and to the same degree as the sleep quality of insomniacs taking 10 mg. of zolpidem (Ambien).

Both studies were small, though, and whether the results would generalize to insomniacs overall is an open question. Also, neither study addresses the question of how long the beneficial effects of acupuncture on sleep might last, with or without continued treatment.

But there don’t seem to be any downsides to acupuncture (though treatment may vary among practitioners trained in different schools). If you’re an insomniac open to experimentation, it might provide just the sort of sleep juice you need.

Too Aroused for Sleep? Try Yoga

Sat Bir Khalsa, a professor and researcher at Harvard Medical School, thinks that among alternative treatments for insomnia, yoga may also be a viable solution for people who feel too aroused to sleep.

I attended Khalsa’s presentation at a conference a while back. Here’s the gist of what he said.

Insomnia sufferers may want to try yoga to prepare for sleepAn acquaintance of mine said she’s often “just too wound up, too hyped up” to sleep.

I know the feeling. It‘s like my body’s stuck in overdrive, and I can’t find the brakes. The best solution for me is physical exercise.

But Sat Bir Khalsa, a professor and researcher at Harvard Medical School, thinks that among alternative treatments for insomnia, yoga may also be a viable solution for people who feel too aroused to sleep. I attended Khalsa’s presentation at a conference a while back, and later I contacted him for more information.

“Yoga works on inducing the relaxation response,” Khalsa said, producing “a reduction in stress system activation. Yoga and meditation practice also changes the perception of stress … creating a positive change in stress tolerance.”

Sounds good to me. But is there proof?

A small number of studies attest to the benefits of yoga as a strategy for managing insomnia, and some of them are randomized controlled trials (RCTs). In RCTs, the results of subjects who undergo a treatment are compared to the results of control subjects who do not, a protocol considered by scientists to meet the highest standard of proof.

  • An RCT conducted in an Indian home for the aged produced spectacular results: subjects who practiced an hour of yoga six days a week for six months increased their total sleep time by a whopping 60 minutes a night! They also reported greater ease in falling asleep and feeling more rested in the morning.*
  • In an RCT published last year, postmenopausal women in Brazil experienced a significant reduction of insomnia symptoms and increased stress resistance following four months of yoga practice.**
  • Khalsa’s RCT, which he discussed at the conference, showed that the sleep of subjects who practiced 45 minutes of yoga before bedtime every day for eight weeks improved substantially more than the sleep of control subjects, who received information about sleep hygiene. Yoga subjects reported increases in total sleep time that were two and three times as great as the increases made by controls. (Again, we’re talking in the neighborhood of 60 minutes’ more sleep a night.)

Yoga may achieve its calming effects in a paradoxical way, Khalsa told me, by increasing levels of the stress hormone cortisol while at the same time improving stress tolerance. The overall effect is to decrease feelings of arousal.

This is why insomniacs – particularly those who tend to feel wound up at night – may want to try it out.

*   Influence of Yoga & Ayurveda on self-rated sleep

** Yoga decreases insomnia in postmenopausal women

A New Look at Trazodone for Sleep

Trazodone has never been approved for the treatment of insomnia. Yet it rose to the top of the bestseller charts as a medication for sleeplessness in the 1990s and enjoys great popularity still. Here’s one explanation for its appeal.

It’s been a stretch for me to accept that trazodone, a sedating antidepressant, is such a popular treatment for insomnia. Clinical trials have never shown it helps put people to sleep or keeps them sleeping longer. And even at low doses (50 mg.), the drug is known to produce cognitive and motor impairments the following day.* Trazodone has never been approved for the treatment of insomnia, yet it rose to the top of the bestseller charts as a medication for sleeplessness in the 1990s and enjoys great popularity still.

Trazodone

Confession: this is the sort of knotty paradox that keeps me awake at night.

Now, I have insomniac friends who swear by trazodone, and I know they’re not delusional. They use low-dose trazodone because it works for them, and they don’t need to understand why.

But I’m a stickler for evidence, and this gap between subjective experience and objective proof is a real sore point. So imagine my thrill at finding a paper that explains why it might be that trazodone works.

Trazodone and REM Sleep

The traditional view of insomnia holds that it’s basically a problem of non-REM (or quiet) sleep. Insomniacs may not be getting the same percent of deep sleep as good sleepers, or the problem may be in how deep sleep is discharged. Deep sleep is the restorative stuff, the kind that “knits up the raveled sleeve of care.” Alternatively, the quality of non-REM sleep may be compromised by lots of high-frequency brain activity that enables you to sense things even while you’re asleep.

But for insomniacs who struggle with frequent awakenings in the middle of the night, the problem may in fact be occurring during REM (or active) sleep, when you’re dreaming. A new analysis shows that percent-wise, people with sleep maintenance insomnia get less REM sleep and awaken more often during REM sleep than good sleepers. The hypothesis is that these insomniacs may be suffering from “REM sleep instability.”**

Despite its otherwise underwhelming characteristics as a sleep medication, trazodone does cut down on nighttime awakenings and make sleep feel easier. Unlike most other antidepressants, the drug does not suppress REM sleep. So as a sleeping pill, trazodone may have a claim to legitimacy after all.

Perhaps you’re one who knew it all along, but I was a skeptic, and this bit of news has done wonders for my sleep!

Effects of Trazodone

** REM Sleep Instability

Food for Sleep

Will a cup of warm milk at bedtime entice the Sandman your way?

Research suggests there’s a link between food and sleep, say the authors of a comprehensive review of the effects of diet on sleep length and quality, and milk is rich in tryptophan, an amino acid important to sleep.

Insomniacs | snack on tryptophan-rich food and carbohydrateWill a cup of warm milk at bedtime entice the Sandman your way?

Research suggests there’s a link between food and sleep, say the authors of a comprehensive review of the effects of diet on sleep length and quality,* and milk is rich in tryptophan, an amino acid important to sleep.

Tryptophan is a precursor to melatonin, the hormone of darkness. Your body begins secreting melatonin a few hours before bedtime, helping you fall asleep and sleep through the night. Tryptophan is also a precursor to serotonin, a neurotransmitter which, in addition to promoting alertness, gets converted into melatonin.

Foods high in tryptophan include

  • Meat, fish, seafood and egg whites
  • Cheese, milk and yogurt
  • Pumpkin and sunflower seeds, cashews, almonds and walnuts
  • Beans, split peas, peanuts and lentils.

The Devil in the Details

But tryptophan has to cross the blood-brain barrier to exert its sleep-inducing effects. It competes with other amino acids to cross that barrier, so a bedtime snack high in tryptophan alone may not yield much bang for the buck.

One way to ensure that lots of dietary tryptophan DOES get across the blood-brain barrier is to have a snack that combines a tryptophan-rich food with a carbohydrate:

  • Milk and cereal
  • Beans and rice
  • A turkey sandwich
  • Hummus on pita bread.

Eating the carbohydrate promotes the release of insulin, which inhibits the production of competing amino acids or diverts them into muscle. With less competition at the gate, more tryptophan gets across the blood-brain barrier. It then begins its conversion into serotonin and melatonin, in turn promoting sleep.

Nutritional deficiencies in the group B vitamins and magnesium have been found to impair sleep, say the authors of the review. A sleep-friendly diet will include foods high in tryptophan and unrefined carbohydrates, as well as group B vitamins and magnesium.

*Diet promotes sleep duration and quality

Melatonin: It’s All About Timing

Most insomniacs I’ve met dismiss melatonin supplements as useless, and with good reason. If you follow directions and take the melatonin an hour before bedtime, it’s little more than a sugar pill.

But taking a melatonin supplement several hours before bedtime may give you better results.

melatonin taken early in the evening more effective than if taken at bedtimeMost insomniacs I’ve met dismiss melatonin supplements as useless, and with good reason. If you follow directions and take the melatonin an hour before bedtime, it’s little more than a sugar pill.

But taking a melatonin supplement several hours before bedtime may give you better results.

Last night I had a chance to test this out. I was flying back to Ann Arbor from California, which meant I was losing 3 hours in my day. Normally I have a hard time shrinking my day by just one hour, as occurs when daylight savings time begins in the spring. I go around feeling logy and sleep-deprived for a couple days. Eastward travel across multiple time zones is even harder. Getting adjusted without sleeping pills is practically impossible!

But yesterday instead of waiting until bedtime to take a sleeping pill, I took melatonin at dinnertime while I was still on the plane. I felt alert through the rest of the flight. Then I drove home, unpacked, and read the Sunday paper.

It was around 11 p.m. that I started feeling sleepy. Forty-five minutes later I was down for the count and slept through the night until 5:30, my normal wake-up time. And this morning I feel good.

How Melatonin Works

Melatonin is a hormone produced by the pineal gland. Secretion typically starts a few hours before your normal bedtime and ends about the time you wake up. In most cases, adding to your body’s natural melatonin by taking a melatonin supplement at bedtime is redundant. Your body has no use for it then.

To fall asleep earlier than you’d normally be ready for sleep, you’ve got to take the melatonin well before your natural melatonin cycle begins. Clinical trials with 3 mg. of melatonin have shown that taking a tablet 7 hours before your established bedtime will advance the timing of your sleep the greatest amount.

In my case, since I’d been going to bed in California around 10 p.m. PST, I took the melatonin yesterday at 3 p.m. PST (6 p.m. EST). And last night I fell asleep more than an hour earlier than I would have otherwise.

Melatonin won’t help you sleep longer, and it won’t necessarily improve the quality of your sleep. But it may well help you get to sleep sooner if you take it late in the afternoon or early in the evening. Timing seems to be the key.

In Praise of Sleeping on the Couch

Sleeping on the couch isn’t always a bad idea. Some insomnia sufferers are light sleepers prone to high-frequency brain activity even during the deeper stages of sleep, or so the experts say. We pick up on information in the environment that normal sleepers readily tune out.

The problem may be that there are disturbances in the bedroom itself.

It’s a telltale sign of denial in people with insomnia, as far as sleep experts are concerned. To sleep anywhere but the bed is to avoid facing up to your real problem with sleep: namely, the fact that your bed has become Enemy No. 1. The frustration of going to bed and being unable to sleep has become associated with the bed itself, so that merely setting foot in the bedroom can make you anxious. Just thinking about B-E-D makes your stomach clench.

Hence, the cowardly retreat to sleeping on the couch.

Well, OK. Most of us would rather sleep in our beds, and if the bed triggers negative associations, there are treatments you can undergo to relieve the situation and they’re worth checking out.

But sleeping on the couch isn’t always a sign of denial. Some insomnia sufferers are light sleepers prone to high-frequency brain activity even during the deeper stages of sleep, or so the experts say. We pick up on information in the environment that normal sleepers readily tune out. The problem may be that there are disturbances in the bedroom itself.

•  Snoring husband? Now, which is the more rational approach to sleep, arguing with an unresponsive husband (“Turn over, you’re snoring.” “Was not.” Were too.” “My head’s already under the pillow.” “Is not.” “Is too.”) or tiptoeing out of the bedroom and into the arms of a nice mute couch?

•  Thrashing wife? Same thing. She may be fighting tigers in her dreams, but are you going to stick around to discuss the fact that she may be the one with sleep problem and shouldn’t she finally go in for that sleep study after all? No way. Head for the couch.

•  You wake up roasting in the sheets? It’s time to take a leaf out of Ben Franklin’s book. Franklin knew heat could sabotage sleep and had a second bed to go to when the first got too warm. Why toss and turn amid sweaty sheets when you can stretch out on a nice cool couch?

•  Moonlight awakens you at 2 a.m.? Is it your fault that your partner leaves the blinds open so he can awaken to sunlight and an alarm clock chanting, “’Twas brillig, and the slithy toves Did gyre and gimble in the wabe?” No, señor! The simple way to solve this problem is to head to the couch in the den.

A couch with all the right accoutrements can be a godsend for insomniacs in a pinch. Do not underestimate us, sleep experts. Sometimes we’re smarter than you think.

Clocking the Hours at Night

Does the sight of a clock at night make you anxious?

Here’s my solution to that.

Clock watching at night fuels anxiety and insomniaA student once described to me the lengths he had to go to in order to get to work on time. He was in my night class, and he was always struggling to stay awake.

“I get up at 4 every morning,” he explained. Or, he added, he was supposed to get up at 4. But often he overslept the alarm. So he’d devised a system where he set four alarm clocks – one at the head, one at the foot, and one on each side of the bed, all facing toward him – to go off at the exact same time. That’s what it took to wake him up. This was one sleep-deprived man!

A quadrumvirate of alarm clocks standing sentry at my bed is my personal vision of hell. Never mind that the piercing clamor in the morning would blast me through the roof. What the mere presence of those clocks would do to my nights is even worse. Knowing that their luminous faces were trained on me like four sets of malevolent eyes, waiting for a flicker of my eyelids to broadcast the passing of time, would seal the deal: I’d never get to sleep at all.

Clock-watching and sleep don’t mix, I’ve discovered through the years. It’s not that otherwise I’m unaware that time is passing. It’s that coming fact to face with a clock at night triggers tension, a reflexive response I haven’t been able to shake despite the many ways I’ve succeeded in improving my sleep in recent years.

I’m not the only insomniac who feels this way. “When you have to work the next day, I think its hard not to watch the clock,” Liz said in an interview on the phone. “You try not to. But when the hours are rolling by, you start to count the hours you’ve got left. It gets to be 3 or 4 in the morning, and you think, ‘Christ, I’ve got to be up by 6!’ That is anxiety …

I’ve learned to turn the clock in my study to the wall an hour or two before bedtime. And the alarm clock on my bedside table is a Brookstone, one of those back-lit types that don’t shine in the dark unless you press down on the top. It’s a small thing, but it’s done wonders for my sleep.