Why It's So Hard to Come By — And What You Can Do About It
By Leslie Crawford
It should be so easy. You're tired. You close your eyes. You fall asleep. But for the millions of Americans who are sleepless in Seattle, Manhattan, and Shaker Heights, this simplest of human functions is but a dream. If there's any comfort in numbers, the insomniac may find solace in knowing she's hardly alone while she pines in the wee hours for Mr. Sandman.
Up to 40 million Americans suffer from sleep disorders, which tend to worsen with age, yet most sheepishly hide it in the closet. (After all, it's only sleep, not a life-threatening illness. And doesn't everyone seem tired these days?) "Too many people think insomnia is something to be embarrassed about, that it's some sort of weakness," says Tom Roth, director of the Sleep Disorders Research Center at the Henry Ford Hospital in Detroit. And this prevents a majority from seeking the help they need.
Happily, researchers bent on unraveling the mysteries of slumber are making headway on finding out why so many of us have ongoing trouble falling or staying asleep. "We're beginning to understand the pathology far better," says Roth, who cites studies finding that some poor sleepers are simply not wired like normal sleepers. Their hearts beat faster, their temperature runs higher, and their levels of the stress hormone cortisol are elevated. In medical terms, they have a condition known as hyperarousal.
Unfortunately, the best way to target this type of insomnia is still not known. "We have miles to go before we sleep," says Roth. But at least this new understanding may alleviate some of the stigma that often comes with it. Practitioners have long viewed insomnia as a symptom of other causes—anxiety, depression, hormonal changes, and the side effects of various medications are among the leading ones. But according to the new research, for many people it may well be a condition unto itself. And "you have trouble sleeping" is a lot easier to take than "this means you must be depressed."
There's also some good news on the treatment front for people who suffer from any type of insomnia. We're not talking about a cure—sleeplessness recurs periodically in most insomniacs. But experts say that most people can find a way to manage insomnia as long as they're willing to keep on trying, even after the first, fifth, and seventh attempts fail. Often the secret lies in combining approaches. "No matter how severe the insomnia," says Jacob Teitelbaum, director of the Annapolis Research Center for Effective Chronic Fatigue Syndrome/Fibromyalgia Therapies, "it's possible for just about everyone to get eight to ten hours of restful sleep."
Practitioners who take a holistic approach to health have lots to offer the sleep-deprived. If anxiety or stress is your problem, they can suggest any number of calming techniques such as yoga, meditation, or aromatherapy. If nutritional deficiencies might be keeping you awake, they can diagnose them and suggest supplements that may help.
No true insomniac comes by solutions overnight. Rather, most endure a tortuous period of trial and error until finding the sleep package that works for them. "As with all chronic problems, some things that work for some people won't work for others," says Kenneth R. Pelletier, clinical professor of medicine at the University of Maryland School of Medicine and author of The Best Alternative Medicine: What Works? What Does Not? But as the following testimonials from four insomniacs who have gone to the edge of night and back suggest, persistence does pay off. Until you find what works for you, keep in mind what may be the most comforting thing you'll ever read about this problem: No one, say the sleep experts, not even the weariest of night owls, has ever completely lost the ability to fall asleep.
Reason for insomnia: Anxiety
"The more I didn't sleep, the more I put pressure on myself to be in top form the following day, which of course only ensured I wouldn't sleep."
In French, it sounds almost charming—la nuit blanche—which translates to "white night." But when Marcel Deymes began to experience insomnia in his mid-forties, the condition rapidly took over his life, so much so that his sleepless nights turned day and night alike into a horror. "My job was taking care of international crises—first in Yugoslavia and later in Iraq," says Deymes, a French diplomat based in Washington, D.C. But it quickly turned into a crisis at home, too.
On top of his 12-hour days, he was studying for a demanding diplomatic-service exam. He had so much going on during the day that he couldn't let go of it all at night. So he would lie there, eyes wide shut, to no avail—and the next day be ragged and weary.
Soon he began drinking heavily before bedtime, hoping the alcohol would knock him out. All it did was make him even more tired the next day. Sleeping pills had the same effect. "Nothing seemed to help," says Deymes. "I just stayed in bed, awake every night, all night." A high-pressure assignment the next morning—giving a speech, say, or leading a meeting of 50 people—only guaranteed that he'd have a night full of anxiety and wouldn't be able to fall asleep, yet again.
When his condition finally became intolerable, a friend suggested he try transcendental meditation (TM). "Marcel took a TM class and it literally changed everything," says his wife, Julia. By helping him siphon off stress, it calmed him enormously, she says. He also began exercising for an hour three or four days a week. "I knew I shouldn't take up running, which would only energize me further," says Deymes. "I needed something heavy and exhausting that would wear me out." He now lifts weights at the end of the day, pushing himself until he's really tired. He also limits his drinking to one glass of red wine at dinner.
"I still get insomnia about once every two months," he says, "but it's no longer a total preoccupation. I've found a way to deal with my tension so I don't take it to bed with me."
What didn't work: Sleeping pills, drinking at bedtime.
What did: Transcendental meditation, lifting heavy weights at the end of the day, and drinking only one glass of red wine with dinner.
Reason for insomnia: Hormonal changes
"When you're sleep-deprived, your life starts to go south. You don't have energy, you're always on edge. It completely altered my personality."
Lesley Goldman remembers the exact night when it struck, eight years ago in November. "I went to bed feeling fine, and slept for two hours," she says. "Then I awoke with a strange feeling of wakefulness—as if I had been driven to wake up." From then on, all her nights followed a similar pattern: She'd lie in bed for two hours, fall asleep for another two, then wake up and stay awake until dawn. "It wasn't long before I was a total wreck," says Goldman, who lives in Freeport, New York.
A year earlier, when menopause hit, Goldman, considered herself one of the lucky ones, making it through without the usual side effects. "My gynecologist said my hormone levels had dropped precipitously, but I felt fine," she says. That is, until insomnia unceremoniously arrived with no apparent intention of leaving. By February, after months of sleeplessness, she had developed high blood pressure and was regularly taking sleeping pills. She also tried a vitamin drip and taking antianxiety medication.
But nothing helped her sleep. Over time she grew increasingly depressed and withdrawn. Finally, her physician referred her to a Vedic doctor practicing at the Maharishi Vedic Health Center in Lancaster, Massachusetts. After assessing all the ways in which her body might be out of balance, he put her on a cleansing program (herbs, oil massages, and enemas), a vegetarian diet, an exercise regimen (walking), and a mix of herbs in capsule form. "I felt so pampered and taken care of, but I still wasn't getting sleep," says Goldman. "They told me not to judge while I was going through the process, but to wait until afterwards." Sure enough, after two weeks at the clinic, she returned home—and finally had her first good night's sleep in years.
These days, Goldman still wakes up in the middle of the night, but the miraculous difference is that she falls right back to sleep. "Literally, my life came back," says Goldman, who now takes several combinations of Indian herbs, including one for blood pressure, and always finds time to go on long walks, meditate, and stretch. "My husband says that it's as if the real me disappeared for a year, and only reemerged after my treatment."
What didn't work: A vitamin drip, antianxiety medication, sleeping pills.
What did: Indian herbs, oil massages, transcendental meditation, a vegetarian diet, daily walks, and lots of stretching.
Reason for insomnia: Hyperarousal
"You feel like you're weak, like something's inherently wrong with you. After all, sleep is the most natural thing in the world, right?"
A high-level media executive in San Jose, California, Patricia Gregory knew she'd reached the breaking point when she began experiencing sleepless nights—night after night after night. "At its worst I thought, 'I can't do this anymore. I am going to have to kill myself.'"
Gregory was hardly a newcomer to insomnia. Even as a child she suffered from occasional bouts, and the cycle continued throughout her teens and into adulthood. Months would go by with no episodes, and then she'd suddenly experience a series of difficult nights. Most frustrating, since she wasn't prone to anxiety or depression, Gregory could never find a reason for her wakefulness. One night she'd sleep beautifully, and the next she'd be revved up and restless. "The best way I can describe the feeling is an inability to shut down," says Gregory.
Still, Gregory's insomnia was sporadic enough that she could suffer through the occasional trying night and manage to carry on as a full-time working mother of two. Then, two years ago, her condition kept her awake for weeks on end and she finally couldn't take it anymore. That's when she decided to seek professional help.
Gregory's physician put her through some tests but couldn't find anything wrong with her, so she was sent to a sleep clinic. The doctor there put her on the antidepressant Paxil, which only succeeded in making Gregory sleepy during the day—and wide awake all night. So after a couple of months, she stopped taking it.
Like her mother, who also has a history of insomnia, Gregory appears to belong to that unique breed of insomniacs who suffer from the condition experts call hyperarousal. Instead of winding down to rest at nighttime, those who are hyperaroused have higher-than-normal metabolic rates, heart rates, body temperature, and levels of the stress hormone cortisol.
The first step toward breaking out of this hellish trap finally came not with herbs or homeopathic remedies, many of which Gregory tried, but with the prescription sleeping pill Ambien. Not only did it finally get her some much-needed sleep, it successfully broke her cycle of sleeplessness. "In a few weeks' time, I regained confidence once again in my ability to get to sleep," says Gregory.
But wary of becoming dependent on the sleeping pills, Gregory vowed to take preventive measures for a condition she understood would always plague her on some level. Giving up caffeine was never a problem—she's always favored herbal tea. But she now makes a point of exercising every day, eating fewer processed and refined foods, and taking a good multivitamin along with extra calcium, magnesium chloride, and fish oil pills.
She also practices deep breathing throughout the day, whenever she thinks of it. And she adheres to a bedtime routine that includes stretching, spritzing her pillow with lavender oil, and flipping on a sound machine. It helps, too, to know that the sleeping pills are there for the occasional night when her routine isn't enough. "I realize I have to be very careful how I treat myself," says Gregory. "This will never completely go away. But at least I now know how to manage it."
What didn't work: Many popular sleep-inducing herbs ("I've tried them all"), antidepressant medication.
What did: Taking nutritional supplements, eating well, deep breathing, creating a bedtime routine that includes lavender spray, a sound machine, and stretching, and—when nothing else works—Ambien.
Reason for insomnia: Life transition, hormonal changes
"At its worst, the turmoil I was experiencing was constant."
When she was 48, Sanni Gentry's life began to unravel. Her marriage of 20-plus years was falling apart just as menopause struck. Two such major life changes brought on a third: sleeplessness. "The stress of my marriage dissolving was enormously severe," says Gentry, who was so anxiety-ridden that she experienced every form of insomnia: trouble falling asleep, trouble staying asleep, and trouble getting a restful night's sleep.
Except for when her children were babies, Gentry, who lives in Fairfield, Iowa, had a lifetime record of never giving sleep a second thought. "As a young person, I went to bed, hit the pillow, and instantly went to sleep," she says. But this time, for several years, her stress and her insomnia were unrelenting. It wasn't until Gentry moved into a place of her own and found a job in her neighborhood health-food store that she began to find her way back to a normal life.
"When I started working at the store I became aware of all the alternatives out there," says Gentry. She cut out sugar and caffeine, switched to eating organic foods, started using an eye pillow, and began experimenting with various herbal and homeopathic remedies. The only one that worked with any consistency was a homeopathic combination by Boiron called Quietude. She also continued practicing transcendental meditation. "Meditation is great for helping the body settle down, and ridding yourself of anxiety," she says. But she credits flower essences for bringing her real relief; she says they help calm and prepare her for the daily stress of life.
Several years after her divorce, Gentry has learned to recognize when she's going too fast which, sure as clockwork, leads to compromised sleep. "I really began to listen more carefully to my body," she says, "and do what I can to head off the anxiety."
What didn't work: Melatonin
What did: The homeopathic remedy Quietude, slowing down, transcendental meditation, flower essences, daubing lavender oil on her forehead every night, an eye pillow, and eliminating sugar and caffeine.
Leslie Crawford lives in San Francisco.
The Insomniac's Tool kit
The first thing insomniacs learn is that what works for a friend won't necessarily help you. In fact, finding the right mix of therapies can itself be exhausting, which is why it makes sense to consult an expert such as a homeopath, Ayurvedic doctor, or other holistic practitioner, who can give you individualized guidance.
Keep in mind that there's a solution for just about everyone—the key is to not give up trying to find it. The following list should help you get started.
Follow the sleeper's diet
"The inability to sleep quite often comes from a combination of a lack of nutrients and dehydration," says Carolyn Dean, an integrative physician in City Island, New York. She steers her insomnia patients toward foods high in calcium, magnesium, and essential fatty acids, and lots of water.
Eat some protein a few hours before going to sleep. Low blood sugar, or hypoglycemia, is a big reason so many people wake in the wee hours. Protein can bring it up and keep it stable. Eat turkey and you'll get the added bonus of tryptophan, which triggers production of sleep-inducing serotonin.
Don't eat big meals (especially spicy ones) for up to three hours before bed; the process of digesting all that food can keep you awake.
Try some sleepy-time elixirs. Those old wives knew whereof they spoke. Old-fashioned potions like hot milk and chamomile tea have sedating properties.
Cut out the caffeine. And keep in mind that even decaffeinated tea and coffee contain some caffeine.
Limit alcohol consumption. A glass of wine can relax you, but more than that can have a boomerang effect: It may knock you out for a couple of hours, then wake you up in the middle of the night.
Create a bedtime routine
Make an art of relaxing. Stress is considered by most sleep experts to be the number one cause of short-term sleeping problems. "When people have too much stress in their lives," says physician Jacob Teitelbaum, in Annapolis, Maryland, "it throws off the hypothalamus, which is the brain's sleep center."
Richard Brown, associate professor of clinical psychiatry at New York's Columbia University and an integrative psychopharmacologist, advises his insomnia patients to learn to relax by taking classes in deep breathing (visit www.artofliving.org to find classes in your area). But any discipline that helps you calm down—yoga, meditation, tai chi, chanting—can make a difference.
Work out some every day. "I can't emphasize enough the importance of pure physical exercise," says University of Maryland medical school professor Kenneth Pelletier, who cites the positive effects of getting the body naturally tired. Even just 15 to 20 minutes of anything that gets you up and moving and breathing hard, can help.
Keep in mind the importance of timing. "If you exercise too late in the evening, " says Efrem Korngold, a San Francisco acupuncturist and coauthor of Between Heaven and Earth: A Guide to Chinese Medicine, "it stimulates rather than relaxes you. Try fitting it in at least two or three hours before going to bed."
Train yourself to sleep. It's important to prime yourself for sleep by giving your body lots of different cues—such as taking a lavender-scented bath, doing a couple of quiet yoga poses, and drinking a mug of steaming milk—so your body and mind get the message on many levels that it's time to relax.
Establish a winding-down period. "You can't do your taxes at 10 at night and expect to go to sleep at 10:15," says Pelletier. "You need at least an hour to just relax before going to sleep to allow time to decompress."
Put television and computers to bed early. These can act as stimulants. Make sure they're quiet at least an hour before you turn in, says Judith Orloff, assistant clinical professor of psychiatry at UCLA.
Stretch slooowly. Doing so just before climbing into the sack can relieve kinks, reduce anxiety, and help your body relax. Many insomniacs get help from yoga stretches.
Find a mantra. "It's particularly useful when you wake up in the middle of the night," says Orloff. "Something that is repetitive and has a rhythm helps you reprogram your mind so you can sleep."
Visualize peace. Get an image in your mind of something that brings you comfort, and focus on that. "I like to imagine a circle of women around my bed watching me and helping me feel safe,"says Orloff.
Listen to relaxation tapes. Look for ones that play sounds and music at the same frequency as delta waves, which are the brain waves you generate while falling asleep. You can find a selection at brain.web-us.com.
Get a sound machine. It creates a soothing blanket of sound that can keep noisy disturbances to a minimum.
Find your favorite sleep aid
"A number of wonderful, natural things can send you off to a sound sleep and leave you feeling great the next day," says Jacob Teitelbaum. But before blithely assuming that anything natural goes, it's best to first consult a practitioner with an expertise in herbs, minerals, and supplements. Some can adversely affect other medications—and vice versa. And while each product carries dosage information, how much to take can vary widely depending on your needs. Here are a few of the most popular:
Herbs: The most widely prescribed herb for sleep is valerian root. Look for Valeriana officinalis (0.8 percent extract). Take 400 to 500 milligrams daily for several weeks for best results. Note: For an estimated 10 percent of users, valerian actually works as a stimulant.
Other sleep-inducing herbs include:
Kava kava: An herb that canrelieve anxiety. Taking it in high dosages or over a long period of time has been linked to liver damage. Don't take more than 300 mg a day, or for longer than four weeks, without medical advice.
Saint-John's-wort: Can treat depression—a common underlying cause of insomnia—without the side effects of antidepressants.
Lavender: Its fragrance is very soothing. Hang a lavender sachet on your bed or daub some lavender oil on your pillow.
Minerals: Some sleep experts say that upping your calcium and, particularly, magnesium intake can induce sleep. "A common source of insomnia is a deficiency of magnesium, a mineral you often lose to stress," says Billie J. Sahley, director of the Pain & Stress Center in San Antonio, Texas. Popular brands include Floradix Liquid Calcium Magnesium, Purdue Products' Slow-Mag, and Natural Vitality's Natural Calm.
Amino acids: The one most commonly prescribed for sleep is 5-hydroxytryptophan (5-HTP), which is what the body uses to produce the sleep-inducing neurotransmitter serotonin. It must be taken daily for several weeks to have an effect, and the standard dose is 50 mg.
Some people also ease anxiety by taking l-theanine, which is found in green tea, or GABA (gamma-aminobutyric acid). Sahley advises dissolving the contents of a capsule of GABA in a glass of water at bedtime so you can sip from it if you wake up in the middle of the night. "The GABA will lower your anxiety and allow you to relax and go back to sleep," she says.
Hormones: Melatonin, a hormone made by the pineal gland, can bring on deep sleep for many.
Sleep formulas: They number in the hundreds. Among the ones practitioners say have helped patients: Enzymatic Therapy's Revitalizing Sleep Formula, which contains valerian, wild lettuce, and other calming herbs; the Pain & Stress Center's Sleep Link, which includes GABA and 5-HTP; and homeopathic formulas, like Nelson's Sleep Aid, Hyland's Insomnia, and Boiron's Quietude.
If all else fails, use sleeping pills—judiciously
Whatever the reason a person can't sleep, sedatives have long been among the most common remedies used and, admittedly, abused. But for many insomniacs, the newer types of prescription medications like Ambien and Sonata are just what the doctor—mainstream or integrative—ordered. "Sometimes the natural things are too gentle," says psychiatrist Richard Brown.
"For some people, a sleeping pill may be really helpful for several weeks to help them get back on track and start sleeping again."
Both pills target the sleep—promoting neurotransmitter GABA; both are short-acting, which means they don't stay in the body long; and neither has many side effects. The problem comes when sleeping pills are used long term. They can become psychologically addictive, and thus distract the insomniac from getting to the root of the problem.
Sleep experts recommend using prescription medicine for only a short time—no more than a few months. "Millions of people are taking sleeping pills long term who shouldn't have to," says Brown. "I prefer to help people change their lifestyle so they're not relying on any sleep aid—natural or chemical." — L.C.