Insomnia Is Not a Trivial Concern

If you’ve struggled with chronic insomnia for years, even if you have some reliable management strategies, you may occasionally find yourself talking about insomnia with people whose looks and responses suggest it can’t be such a big deal.

“Aren’t there pills for that?” “My doctor says that’s self-inflicted. You just THINK you can’t sleep.” Here’s some new research that shows why persistent insomnia is a serious problem deserving of concern and treatment.

Talking about insomnia with friends.If you’ve struggled with chronic insomnia for years, even if you have some reliable management strategies, you may occasionally find yourself talking about insomnia with people whose looks and responses suggest it can’t be such a big deal.

“Aren’t there pills for that?”

“My doctor says that’s self-inflicted. You just THINK you can’t sleep.”

Here’s some new research that shows why persistent insomnia is a serious problem deserving of concern and treatment.

Benefits of Sleep

First, though, let’s review the central role sleep plays in maintaining well-being. In the past, people thought that nothing much happened during sleep and that the human brain essentially shut down at night. How wrong that notion was!

Many critical functions occur during sleep. Sleep enables the shoring up of the immune system and the repair of injuries. During sleep, memories are consolidated and brain waste is pruned. Negative emotion is processed during REM sleep. After a full night’s sleep you awaken in a more positive mood. During sleep energy is conserved. In the morning you awaken feeling rested and restored, and your brain is primed to learn and retain new information.

When sleep is disrupted, whatever the reason, the critical functions that take place during sleep may be compromised. In the case of chronic insomnia, common symptoms during the daytime—tiredness and lack of stamina; moodiness; and impaired attention, concentration, and memory—are suggestive of compromise. They cut down on the quality of our day-to-day lives.

Effects of Persistent Insomnia Over Time

Chronic insomnia also has several more insidious effects.

It increases the odds of our developing depression and anxiety. A new meta-analysis of studies on insomnia as predictor of mental illness has found that chronic insomnia makes us nearly 3 times as likely to develop major depressive disorder and over 3 times as likely to develop an anxiety disorder as people without insomnia.

Insomnia and Chronic Pain

Insomnia intensifies and increases susceptibility to pain. Past research has suggested that the relationship between insomnia and pain is bidirectional, with painful conditions interfering with sleep and sleep disturbances worsening painful conditions. But recent longitudinal studies (studies involving repeated observations over time) suggest that more often it’s insomnia symptoms that predispose us to chronic pain or to the worsening of painful conditions.

Insomnia and Heart Disease

Insomnia, especially when accompanied by objectively measured short sleep duration (less than 6 hours), makes us more susceptible to heart, or cardiovascular, disease (CVD). Meta-analyses have found that people with insomnia are between 33% and 45% more likely to develop and/or die of CVD than people without insomnia.

A new study of sleep duration and atherosclerosis (plaque formation in arteries) has found that short sleepers are 27% more susceptible to atherosclerosis than people who sleep 7 to 8 hours a night, and those whose sleep is highly fragmented are at even greater risk (34%) for plaque build-up.

A disorder that has so many negative effects on quality of life and long-term health cannot be dismissed as a minor annoyance. It’s important to get treatment for insomnia as soon as possible, with cognitive behavioral therapy or, in cases that don’t respond to CBT, medication.

Talking About Things We Know

Despite what you might infer from the fact that I blog about insomnia, I don’t go around seeking opportunities to talk about the problem in my everyday life. Sleep disorders now get quite a bit of attention in popular media, but most of us know the topic has the appeal of moldy leftovers for the good sleepers of the world — and they are in the majority.

Occasionally, though, conversations turn to talk about sleep, at a party or a meeting or anywhere in casual conversation. And who better than us to raise people’s awareness about the problem of insomnia since we’re the ones with all the experience?

If you’ve talked about insomnia with your family, friends, or acquaintances, what has been their reaction?

Get Rid of Unfounded Ideas About Sleep

People sometimes ask whether chronic insomnia is mainly a physiological or a psychological problem. Often it’s both.

Certain beliefs about sleep can interfere with getting a good night’s rest. A reality check can help you sort out truth from myth, which in turn may help you sleep.

Insomniacs will sleep better if they're rid of erroneous ideas about sleepPeople sometimes ask whether chronic insomnia is mainly a physiological or a psychological problem. Often it’s both.

High reactivity to stress—whether strictly biological or due to a combination of biological and environmental factors—may predispose you to insomnia. But there’s probably a psychological aspect to the problem if insomnia is a persistent feature of your life.

Certain beliefs about sleep can interfere with getting a good night’s rest. A reality check can help you sort out truth from myth, which in turn may help you sleep.

I need 8 hours of sleep a night to function well.

If the National Sleep Foundation (NSF) recommends 7 to 9 hours of sleep for young and middle-aged adults and 7 to 8 hours for older adults, then it follows that 8 hours of shut-eye is the gold standard, right?

Not necessarily.

Sleep experts still haven’t figured out how to measure an individual’s sleep need. Prescriptions like the NSF’s are based on huge data sets containing information about sleep duration and longevity. The data, when graphed, fall into a U-shaped curve, with people whose sleep duration falls in the middle of the curve outliving those at both ends (i.e., the really short and really long sleepers).

Authors of recent analyses have concluded that it’s the 7-hour, and not the 8-hour, sleepers who live the longest. And in an early study involving data from over a million patients, people who slept 6.5–7.4 hours outlived the rest.

Keep in mind, too, that data on sleep duration in these big, retrospective analyses are usually based on subjective estimates, not on objective measures of sleep time. Finally, the recommendations on sleep duration set forth by the NSF panel are offered with this caveat: “some individuals might sleep longer or shorter than the recommended times with no adverse effects.”

You may think you need 8 hours of sleep based on personal experience. Especially if you’re not sleeping well, an 8-hour night can feel heavenly. But to assume you need 8 hours of sleep every night is a mistake.

There’s an average amount of sleep each of us needs for peak functioning. Normal sleepers, whose sleep periods are fairly regular, can estimate their sleep need pretty easily based on the time they drop off and wake up.

But insomniacs’ sleep is often erratic—2 or 3 bad nights followed by a good night—with the pattern repeating again and again. Sleep need on a given night is based on several factors: how long you’ve been awake, what you did during the day, and prior sleep. You may need 8 hours of sleep following several stressful days and short nights. But your average sleep need may be more like 6 or 6.5 hours a night.

I’m worried insomnia is going to do serious damage to my health.

Chronic insomnia is a risk factor for several nasty ailments: cardiovascular disease, depression, and fibromyalgia, to name a few. But saying something is a “risk factor” for something else does not imply causality. It simply indicates a correlation between one thing and another.

For example, if chronic insomnia is a risk factor for whiplash (it is), insomnia makes you more vulnerable to whiplash but does not indicate that you will develop whiplash. Even if you have chronic insomnia, the statistical probability of your developing whiplash is still relatively low.

Why scare the sleepless with talk of health problems we may or may not develop? Well, for years insomnia was dismissed as a trivial complaint without consequence. The fact that it has now been shown to have a relationship with other serious ailments makes it clear that insomnia is worthy of attention and treatment, and that insomnia research is worthy of funding. This is actually a boon for us.

All it takes is one bad night and my sleep is toast for the rest of the week.

If you’ve got chronic insomnia, it may be that sleeping poorly triggers anxiety about sleep, which in turn may make sleep more difficult the following night. Anxiety and worry are rarely compatible with sleep.

But as mentioned before, there’s an average amount of sleep each of us needs to function. You may not actually be aware of the amount you need, but your body IS aware of that amount. In fact, there’s a mechanism—the sleep homeostat—with a set point that keeps track of how much you sleep every night.

A bad night is going to register with the sleep homeostat as an inadequate amount of sleep. The result will be a greater build-up of sleep pressure the following night. Two bad nights will result in even greater pressure to sleep on the third night . . . and so on.

So while negative thoughts about sleep can prolong sleeplessness, an array of forces inside your body are actually working to promote sleep. They always win out in the end.

What ideas about sleep cause you the most anxiety?

Anxiety? Cranial Electrotherapy Stimulation May Help

If you have chronic insomnia, you may have developed anxiety about sleep. I had lots of sleep-related anxiety until I went through sleep restriction. Once my sleep stabilized, the anxiety disappeared.

Studies have shown that cranial electrotherapy stimulation (CES) is modestly effective at controlling anxiety. It’s FDA approved and widely used in the armed forces for anxiety, PTSD, insomnia, and depression.

Anxiety, PTSD, insomnia, & depression respond to treatment with CESIf you have chronic insomnia, you may have developed anxiety about sleep. I had lots of sleep-related anxiety until I went through sleep restriction. Once my sleep stabilized, the anxiety disappeared.

If you go through cognitive behavioral therapy for insomnia (CBT-I), your therapist may address sleep-related anxiety by challenging some of your ideas and beliefs about sleep. This approach works for some insomniacs, research shows. But others remain anxious at the approach of bedtime and look for alternative treatments.

Studies have shown that cranial electrotherapy stimulation (CES) is modestly effective at controlling anxiety. It’s not endorsed as an insomnia treatment by the American Academy of Sleep Medicine. But it’s FDA approved and widely used in the armed forces for anxiety, PTSD, insomnia, and depression. Here’s more about it.

What CES Is and Does

CES is a treatment you administer on your own with a device that sends mild, pulsed, alternating electrical current to the brain via electrodes placed on the earlobes. When the device is turned on, most people feel nothing at all (a few report feeling a slight pulsing at contact points on the earlobes).

The electrical pulses trigger changes in the brain. When UCLA researchers used a functional MRI scanner to look inside the brains of people undergoing CES, they found evidence of two things:

  1. Decreased neural activity in three areas of the brain: the frontal, parietal, and posterior midline regions.
  2. Altered connectivity in the default mode network (DMN). The DMN is a network comprising several areas of the brain that are active during restful alertness, daydreaming, thinking about self or others, remembering the past, and planning for the future. It’s activated by default, when your attention is not focused on performing a task or on some aspect of the outside world.

Why CES Might Help

A device that decreases neural activity might be useful for people with insomnia, which is associated with hyperarousal. Or, by introducing high- or low-frequency cortical “noise,” CES may change activity in the cerebral cortex in helpful ways. It might produce an increase in alpha activity (associated with relaxation), as other studies have shown.

CES may also achieve its effects by altering communication between the nodes of the DMN. Studies of people with depression and anxiety have detected abnormalities in these connectivity networks—abnormalities whose effects may be lessened with CES. Changes in the DMN may help people disengage from worry and rumination and/or focus on things outside themselves.

Safety and Effectiveness of CES

Studies of CES suggest that devices such as Alpha-Stim, the Fisher Wallace Stimulator, and CES Ultra are quite safe. The FDA reclassified the devices two years ago. Now they’re in the same risk category as acupuncture needles and power wheelchairs. Adverse effects from CES—such as headaches and skin irritation under the electrodes—are rare.

As for effectiveness, while several controlled trials of CES have been conducted, the only consistent result obtained is that compared with sham treatment, CES was effective in reducing anxiety.

In a recent survey of veterans and service members using CES devices, 67% of the 145 who answered all the questions reported improvement in anxiety; 63%, improvement in PTSD; 65%, improvement in insomnia; and 54%, improvement in depression. But many of the respondents were also using medication for symptom mitigation, so it’s hard to know how much of the benefit was due to the CES device and how much, to medication.

If you try using a CES device (or if you tried one in the past), please comment on whether it helps.

Sleep Problems Following a Stressful Childhood

Only a minority of the insomnia sufferers I interviewed for The Savvy Insomniac said their insomnia began in childhood. But regardless of when their sleep problem began, a number reported having had stressful and/or abusive experiences in childhood.

Is there a relationship between adverse childhood experiences and insomnia later in life? Anecdotal and scientific evidence suggests there is.

insomnia can occur following a stressful childhoodOnly a minority of the insomnia sufferers I interviewed for The Savvy Insomniac said their insomnia began in childhood. But regardless of when their sleep problem began, a number reported having had stressful and/or abusive experiences in childhood.

Is there a relationship between adverse childhood experiences and insomnia later in life? Anecdotal and scientific evidence suggests there is.

Difficult Childhoods

Liz’s insomnia started in adulthood, worsening around the time of menopause. But she remembered being “a very, very nervous, anxious child”:

I have my suspicions that my trouble sleeping goes back a long, long way. My mother and father had difficulties and they fought a lot, and that made me anxious. I don’t think I feared for myself so much as I felt a general anxiousness about the disruption. Then I had a brother who was 6 years older than me and was always getting into trouble. He grew up with his father away in Egypt during the war. All of sudden he was 6 years old and he had a father and there were major problems between them. That was another disruption, another source of anxiety for me.

Keith thought it was the pattern of abuse he experienced at the hands of a family member that set him up for trouble sleeping:

I experienced severe childhood abuse—physical, emotional, and sexual abuse. It started when I was young and continued a long, long time. It happened early in the morning. When I wake up early now, and I often do, there’s frustration that I’m not able to sleep because I’m vigilant, I’m unable to relax. I’m pretty sure the childhood abuse is the source of my sleep difficulties.

What the Research Shows

Adverse childhood experiences (ACEs) increase people’s susceptibility to health problems later in life. The relationship between ACEs and mental illness, substance abuse, and heart disease is well documented. A recent literature review conducted by Harvard researchers shows that children who experience trauma are also more vulnerable to sleep disorders as adults.

In a majority of studies documenting this relationship, sleep problems were assessed subjectively, by the patients or participants themselves:

  • In a retrospective study of data collected from 17,337 HMO members, trouble falling and staying asleep was significantly associated with several types of childhood trauma: (1) physical abuse, (2) sexual abuse, (3) emotional abuse, (4) witnessing domestic violence, (5) household substance abuse, (6) household mental illness, (7)parental separation or divorce, and (8) household member imprisonment.
  • In a subsequent study, the authors found these same ACEs to be associated with frequent insufficient sleep.
  • In a longitudinal study, children who experienced family conflict between the ages of 7 and 15 were more likely to report insomnia at age 18.
  • Among women overall, there was a strong association between childhood sexual abuse and sleep disturbances reported in adulthood.

In two studies, sleep problems were assessed objectively using a wristwatch-type device:

  • Among 39 insomnia patients, a history of abuse and neglect explained a moderate amount of variance in sleep onset latency (39%), sleep efficiency (37%), number of body movements (40%) and moving time in bed (36%).
  • Among 48 psychiatric outpatients, childhood stress load was a correlate of total sleep time, sleep latency, sleep efficiency, and number of body movements.

Finally, the more traumatic childhood events people reported, the poorer was their quality of sleep:

  • People who experienced 1 to 2 ACEs were twice as likely to report poor sleep quality as people with no ACEs. People who experienced 3 to 6 ACEs were 3.5 times as likely to experience poor quality sleep as people with no ACEs.
  • As the number of ACEs went up, so did the prevalence of insufficient sleep.

Clearly adverse childhood experiences make it more likely that people will develop chronic insomnia or insomnia symptoms in adulthood. I did not experience familial abuse or neglect. I’m guessing, though, that the bullying I experienced one year at school increased my susceptibility to insomnia . . . but that’s a topic for another blog post.

How about you? Do you think there’s a link between your trouble sleeping and adversity you experienced in your youth?

What Makes You Vulnerable to Insomnia?

The causes of insomnia are still unknown, but many factors can make people more and less vulnerable to it.

A prospective study of Norwegian nurses offers new evidence of several factors, some well known and others that have gotten less attention in the past.

vulnerability to insomnia depends on several thingsWhen I set out to write my book about insomnia, I asked dozens of insomniacs what they thought had caused their insomnia. Several mentioned constitutional factors.

There are certainly grounds for thinking that a genetic component is involved. People who have a first-degree relative with insomnia are 7 times as likely to suffer insomnia as people without insomnia in the immediate family.

Other people I interviewed attributed their insomnia to stress at work or to family problems. Still others blamed their insomnia on an inability to quiet their mind at night.

The causes of insomnia are still unknown, but many factors can make people more and less vulnerable to it. A prospective study of Norwegian nurses offers new evidence of several factors, some well known and others that have gotten less attention in the past.

Anxiety and Depression

There’s plenty of evidence pointing to a relationship between insomnia and mood disorders. In the nurses’ study, where investigators reviewed data on 799 nurses collected at 2 time points 2 years apart, nurses higher on anxiety and depression measures in 2009 were significantly more likely to report insomnia symptoms in 2011.

The reverse relationship also held for insomnia and anxiety: nurses reporting insomnia in 2009 were more likely to have developed anxiety 2 years later. Surprisingly, although insomnia is widely understood to be a causal factor in depression, the nurses’ study found no evidence of this.

Morningness and Eveningness

The nurses in this study were all shift workers. Other research has suggested that people who dislike getting up early in the morning have an easier time adapting to shift work, where work at night is required.

In the current study, though, the nurses who disliked getting up early in the morning were actually more inclined to develop insomnia than the early risers. Other research has shown that people who like to get up early tend to have better lifestyle regularity and more regular sleep habits. Both these things tend to protect people from developing insomnia.

Personality Traits

Some people function quite well despite sleep loss while others feel drowsy and lethargic. (This is largely determined by genetic factors and is thus a stable trait.) Languidity—the tendency to experience drowsiness and lethargy after losing sleep—was found in the nurses’ study to predict an increase in insomnia symptoms over the 2-year period. No surprises here. Impairments in daytime functioning are classic symptoms of insomnia.

Another personality trait—flexibility, or the ability to sleep or stay awake at odd hours—has generally been known to protect against the development of insomnia. Among shift workers, this would be an especially useful trait. But in this study, a high score on flexibility had no positive or negative relationship with insomnia.

Smoking, Drinking, and Caffeine

The overall harmful effects of tobacco, alcohol, and caffeine on sleep are now well known. For many years insomnia was attributed to people drinking too much scotch or too much coffee.

More recently, studies have shown that people with insomnia do not typically drink more alcohol or caffeinated drinks than people who sleep well, and the nurses’ study supports this finding. None of these lifestyle factors predicted an increase in insomnia over time. In fact, nurses reporting insomnia symptoms in 2009 actually reported drinking less caffeine in 2011.

Bullying at Work

Several work-related stressors are known to increase the risk of poor quality sleep, and bullying—persistent exposure to negative actions from others—is one. Day-to-day contact with tyrannical bosses and manipulative supervisors often leads to psychological distress.

Nurses subjected to bullying at work reported more insomnia symptoms over time than the nurses working under better conditions. No surprises here: the worry and stress that result from bullying are two of the leading causes of sleep problems among workers.

Spillover Between Work and Family

Stress in one domain can affect another. In the nurses’ study, negative spillover from work to family and from family to work predicted an increase in insomnia symptoms over time. Conversely, insomnia led to reports of more work-to-family conflicts over time.

Shift Work

Finally, shift work, involving night work and rotating shifts, is known to precipitate insomnia. But in this group of nurses, the association did not hold. This unexpected result might be due to the young age of the nurses (average age 33) and their overall good health compared with shift-working nurses overall, many of whom likely self-selected out of the study.

What factors do you think led to your insomnia?

Q&A: Panic About Insomnia Relapse

Lately I’ve been hearing from people who improved their sleep using sleep restriction or full-blown CBT for insomnia (CBT-I) and then experience a relapse. They have a few bad nights and fear they’ve lost all the gains they made. Here’s how one reader recently described her plight:

“I realize that sometimes I will get scared when I have one or two bad nights once in a while. I’m afraid that insomnia will haunt me once again. Is this normal? What can I do?”

Insomnia sufferers should do something quiet at night until they're sleepyLately I’ve been hearing from people who improved their sleep using sleep restriction or full-blown CBT for insomnia (CBT-I) and then experience a relapse. They have a few bad nights and fear they’ll never sleep well again. Here’s how one reader recently described her plight:

 

 

I realize that sometimes I will get scared when I have one or two bad nights once in a while. I’m afraid that insomnia will haunt me once again. Is this normal? What can I do?

Normal or Abnormal?

When cognitive behavioral therapies for chronic insomnia work—and they do improve sleep for 70 to 80 percent of the insomniacs who try them—it can feel like such an achievement. “At last,” you think, “I’ve got this monkey off my back!”

In reality, though, only a minority of the people who undergo CBT-I report that their insomnia is “cured.” The rest of us experience occasional insomnia relapses.

As anyone who’s read The Savvy Insomniac knows, I went through CBT-I with a group of 4 other insomnia sufferers. At the final group meeting, the therapist gave us a handout on how to maintain the gains made during treatment and what to do in case of relapse. Not only are occasional relapses not abnormal; for many of us, they’re probably inevitable.

All Is Not Lost

The first relapse can feel like such a downer and provoke lots of anxiety. “What? I restricted my sleep only to end up right back where I started, and maybe even worse?” It’s easy to appraise the situation this way: you’re short on sleep, fatigued, and out of sorts. Everything about it feels depressingly déjà vu.

But all is not lost. What occurs during CBT-I is a process some scientists liken to a rewiring of the brain. Neural pathways related to new thoughts and behaviors are established as sleep becomes more regular and the bed and the bedroom come to be associated with sleep.

Older pathways active during insomnia do not disappear. Rather, the new pathways—to continue speaking figuratively—are superimposed on the old. With every good night of sleep, neural connections along the new pathways are strengthened. You expect to sleep well at night and you do.

The older pathways and ways of thinking are still there, though, and due to stress or anything else disruptive to sleep, they may regain some influence. Insomnia returns, and you’re as anxious about it as you ever were. But there’s good news, too: once the newer pathways are established, they’re easier to return to.

I’ll attest to this from personal experience. Before I went through CBT-I (and sleep restriction therapy), my bouts of insomnia could drag on for weeks. Now when I experience insomnia and (in rare cases) my fear of sleeplessness returns, I’m able to return to better sleep and dispense with the anxiety in a few days. I do it pretty much by following instructions I received during CBT-I. Here’s how:

What To Do in Case of Relapse

  • Don’t go to bed unless you’re sleepy. If after 15 to 20 minutes you’re not asleep, get up, go to another room, and do something quiet until you’re sleepy again. Then return to bed. If this doesn’t help after a few days, try the next suggestion.
  • Restrict your sleep by an hour or more for a few days. Be strict about getting out of bed at a consistent wake time—even on weekends.
  • Once your sleep is solid again, extend your time in bed by half-hour increments every 2 nights until you return to your desired bedtime.
  • Be sure to get daily aerobic exercise throughout the process.

If you’ve experienced a relapse of insomnia, please take a minute to share how you got your sleep back on track.

Insomnia: Still Don’t Ask, Don’t Tell

I went to my family physician for a routine physical last week. I hadn’t had one in a while, so I decided to get the exam and requisitions for the usual blood work.

This doctor is one whose opinions I respect. But I never hesitate to speak up when information I have leads me to question those opinions. One topic we’ve had discussions about is insomnia and sleeping pills.

Insomnia may be something that doctors avoid bringing upI went to my family physician for a routine physical last week. I hadn’t had one in a while, so I decided to get the exam and requisitions for the usual blood work.

This doctor is one whose opinions I respect. But I never hesitate to speak up when information I have leads me to question those opinions. One topic we’ve had discussions about is insomnia and sleeping pills.

I use Ambien rarely now—sometimes only half a pill—and I’ve still got plenty left from the prescription she wrote last year. So I didn’t plan to mention sleeping pills or insomnia because I didn’t need to.

 

In the Consulting Room

The nurse sat down at the computer to update my medical record, asking about medications and supplements.

Yes, I was still using Ambien. No, I didn’t need a refill.

The nurse then walked out and the doctor walked in.

So what could she do for me today?

I explained the routine nature of my visit and that I wanted the usual blood tests.

She listened to my heart and lungs, placed her fingers under my jaw to feel for lumps, checked my ears and throat. She verified that my weight was stable and that I was getting regular exercise. She typed the lab requisitions into the computer and said I could pick them up on my way out. Then she left.

After the Consultation

Putting on my coat and boots, I happened to glance at the computer, where my medical record was still open. Three words jumped out, the only ones in bold red letters at the top right side of the screen: CHRONIC INSOMNIA. ANXIETY.

The sight was jarring. These words—diagnoses my doctor and I had talked about—felt like accusations. Why, at that moment, did everything I’d learned in my years of studying insomnia—its association with hyperarousal, the stigma attached to it and other disorders involving the brain, the work I’d done to learn to manage my sleep—fly out the window and leave me feeling bad about myself?

I scanned the record for other diagnoses and found one. It appeared in regular black type on the left.

A comment made by a friend of mine suddenly came to mind:

“Usually doctors are hesitant to prescribe sleeping pills for regular use,” she said, “and I’m hesitant to ask. Having worked in a medical office, I think that when you ask for pain pills a lot, or sleeping pills or muscle relaxants or anti-anxiety things, that’s a red flag for being a drug abuser.”

A red flag for being a drug abuser—was that why chronic insomnia and anxiety were at the top of my record in boldface and red? Because several medications used to treat sleep problems and anxiety are controlled substances and I use one? After decades of responsible use of sleeping pills—never using more than a few at a time, never developing tolerance or dependency—am I still seen as a potential drug abuser by my doctor?

The Question Not Asked

Later another thought came to mind. Chronic insomnia is the first thing anyone would see in my medical record, so why had the doctor not asked about my sleep?

I can’t exactly fault her for the omission. She may have assumed, since I didn’t raise the issue myself and didn’t need a sleeping pill prescription, that my sleep must be fine. She may have remembered other conversations we’ve had about my sleep problem—conversations involving some emotion—and decided to leave well enough alone.

All the same, it would have been nice if she’d asked about my sleep. In my imagination, that conversation would go something like this:

Dr: So how’s your sleep these days?

Me: Never better.

Dr: Really?

Me: Yes. With all the study and experimentation I’ve done, I think I’m managing my sleep about as well as a person prone to stress-related sleep disturbance can. There’s not much backsliding these days.

Dr: That’s wonderful. That’s an achievement.

Me: Yes. It is.

Does your doctor routinely ask about your sleep?

Kava for Anxiety and Insomnia: Effective? Safe?

Kava (Piper methysticum) holds promise as an alternative treatment for anxiety and insomnia. But I’ve refrained from blogging about kava and kava supplements due to concerns about liver toxicity.

Now a comprehensive review funded by the National Science Foundation and published in the journal Fitoterapia has eased those concerns. I can write about kava, native to Hawaii and other Pacific islands, as I would any other medicinal plant, summarizing benefits and risks.

Kava, an alternative treatment for anxiety, may also help insomnia sufferersKava (Piper methysticum) holds promise as an alternative treatment for anxiety and insomnia. But I’ve refrained from blogging about kava and kava supplements due to concerns about liver toxicity.

Now a comprehensive review funded by the National Science Foundation and published in the journal Fitoterapia has eased those concerns. I can write about kava, native to Hawaii and other Pacific islands, as I would any other medicinal plant, summarizing benefits and risks.

Kava in Traditional Pacific Cultures

Traditional Pacific island cultures viewed the beverage they prepared from the kava root as sacred. Kava “was the food of the gods,” Hawaiian scholar Mary Kawena Pukui said. “No religious ritual was complete without it.”

Librarian-scholar Margaret Titcomb wrote that the custom of drinking kava “is of interest in Hawaii because it was a sacred drink of importance in many phases of Hawaiian life. . . . Its effect is to relax mind and body. . . . Medical kahunas (learned men) had many uses for it. . . . It was essential on occasions of hospitality and feasting, and as the drink of pleasure of the chiefs.”

Pacific islanders continue drinking kava today. Traditionally it’s mixed with water, strained by hand, and served on social occasions, often in coconut shells. Kava drinkers may consume several coconut shells of the beverage on one occasion.

Western Interest in Kava

Pacific islanders used different parts of the kava plant to treat various ailments, suggesting to Europeans who arrived in the 18th century that kava might have important medicinal uses. First the Europeans used it to treat venereal disease. By the 1880s, it was being used to relieve stress and anxiety. British herbalists have used it since the early 1900s to treat disorders of the urinary tract.

Kava in the 1990s became a popular herbal remedy for anxiety—an alternative treatment to benzodiazepine drugs such as Valium and Xanax. Consumed as a tablet or a tincture, kava supplements contain specific concentrations of kavalactones, which are extracted from the kava plant with alcohol, acetone, or water. Kavalactones are believed to be the main active ingredients in kava.

Anti-Anxiety and Sedative Effects

Studies of kava’s effects on animals show that it acts on many of the same neurotransmitter systems as anti-anxiety drugs. It results in GABA channel modulation and downregulates or inhibits systems that are active during arousal. In humans, quite a few studies have shown that kava is significantly more effective than placebo at lowering anxiety.

So far, though, only one randomized controlled trial has been conducted to investigate kava’s effects on sleep. In this 4-week study of people with sleep disturbances associated with anxiety, the authors compared 34 participants taking a kava extract with 27 participants taking placebo. By the end of the study, the kava group experienced a significant improvement in the quality of their sleep—but so did the group taking a placebo, although to a lesser extent.

So would taking a kava supplement improve the sleep of insomnia sufferers? No one knows, and no one will know unless more and better controlled studies are done. What the existing data do suggest is that kava might be helpful for people whose insomnia is closely associated with anxiety.

Why So Little Research?

Kava sales in the West fell off sharply at the turn of the 21st century. No Pacific islander was ever known to suffer liver failure related to kava, but between 1999 and 2002, 10 kava users in Europe and the United States had to undergo liver transplants. The need for the transplants was attributed to patients’ having consumed moderate doses of kava for anywhere from 2 to 12 months. Subsequently the CDC issued advisories in the United States. Germany banned kava in 2002.

On further examination, though, investigators found that kava could be implicated as a causal agent in only 3 liver failure cases. Germany overturned its ban on kava in 2014. Sales of kava products in the West are expected to rise again.

How Likely Is Liver Failure?

Why kava might trigger liver failure in a few of the millions of users is still an open question. It might have to do with

  • genetic factors;
  • the method of extraction. While the traditional drink is prepared by water extraction, extraction using acetone, ethanol, or methanol is used in the manufacture of supplements to achieve higher concentrations of kavalactones (which, most research suggests, are not themselves a source of toxicity);
  • interactions with drugs such as alcohol, barbiturates, and benzodiazepines;
  • the use of leaves, stems, and other plant parts in the manufacture of supplements rather than just the root; or
  • the use of inappropriate kava cultivars.

All these possibilities notwithstanding, instances of kava toxicity are relatively rare. Say authors of the review, “The incident rate of liver toxicity due to kava is one in 60 to 125 million patients.”

So the risk is pretty slim.

Have you tried kava for sleep or anxiety? How did you fare?