It was a pleasure to talk with journalist Sheila Cain about my approach to treating sleep disorders. The article is now published in Seattle magazine’s Top Doc issue (July).
My favorite excerpt is: “My primary care doctor gave me a printout of things to try, then told me to go home and do them,” Crocker said. “With Dr. Darley, we worked on a very individualized plan that was specific to me.”
The thing I love most is the way in which each person’s sleepless story is unique, even if each one is coming in for what appears to be the same ‘insomnia’ complaint. Taking the time in the first appointment to really understand how the sleep problem developed, how it impacts their quality of life, and the individual lifestyle makes all the difference in making an individual treatment plan that works.
Sometimes in an appointment a patient and I will have moments where we are communicating so clearly, heart to heart, and getting to the root of the sleeplessness. Those times I imagine if someone took a picture there’d be a big light bulb over both of us. Those break through moments make this work worth every effort.
Being unable to sleep can be very distressing, especially when it’s an acute episode. One analogy that works when I think about treating insomnia is that Curing Insomnia is Like Climbing a Mountain.
Think about going for a hike up a mountain to the scenic view from the peak. You look at the paths that lead to the top, and choose the one that’s best for you. Your choice is based on where you came from, your preferences (a long gradual climb, or a short steep one), and your other abilities or conditions. Once you choose your path you stick with it, knowing that if you switch to another path, that horizontal movement is not getting you any closer to the goal.
It’s helpful to think of curing insomnia in a similar way, that you look at the treatment options available to you, and choose the one that’s the best fit. Once you’ve selected the treatment you want, stick with it long enough for it to be effective. Sometimes when people are in an acute episode of insomnia it is tempting to try different treatments, each for a short time. What’s more effective is to give a reasonable trial of a treatment approach (several weeks or a month at least), before switching paths. Knowing that insomnia is cured one night at a time, bit by bit, just like climbing a mountain can help keep you calm and focused on the end goal.
Here’s to the view from the top, and the peaceful sleep at the end of the path!
Many people ask me “Does a warm bath help sleep, or is that just a myth?” The research shows . . .
Yes, it seems to help somewhat. Medical research has investigated the impact of both baths and foot baths on sleep. One study in older people with sleep disturbance found that a 40 minute footbath at 41C decreased wakefulness in the second nonREM sleep period. Women undergoing chemotherapy for cancer have also found increased sleep quality with a warm footbath. Another study done in elderly insomniacs found that a full-body bath (immersed to the mid-chest) for 30 minutes at 40-41C did increase deep sleep, and caused people to experience a good night sleep. .
How does a warm bath improve sleep? Human body temperature is not constant, but varies with a consistent circadian rhythm. There is a slight dip in body temperature at approximately 1pm, and then a more significant drop in the evening hours. We get that sleepy feeling as our body temperature drops. The bath effectively raises our body temperature, and the subsequent drop helps sleep. The bath should be about 60-90 minutes before bedtime.
Of all the means you can use to improve your sleep, this one seems one of the most simple, with the least possible negative side effects. This is a good therapy to try first before using other, more invasive medicine.
In past posts we’ve talked about the impact alcohol can have on sleep, which is widely known. Nicotine also has an impact, which seems less well known by the public.
Studies show that nicotine changes sleep, so that it takes longer to fall asleep initially, people sleep a lower percentage of the time in bed, and REM sleep and total sleep time is decreased. None of these are effects we want!
According to the Centers for Disease Control “In 2010, 43.5 million adults (19.3%) in the United States were current smokers—21.5% of men and 17.3% of women.” So that’s about 1 in 5 people who are exposing themselves to nicotine, and suffering the consequences on their sleep.
If you are someone who struggles with sleep, and smokes, it may be worth the effort to stop smoking in order to improve your sleep, and reap all the other health benefits too. Many state health departments have ‘Stop Smoking’ helplines, and your primary care physician can assist you.
Many people talk to me about their difficulties sleeping, either difficulty falling asleep initially, or returning to sleep in the middle of the night, or in some cases waking up before they want to start the day.
One question that can be very helpful in this situation is “what woke you?” or “what prevented you from falling asleep?” Surprisingly often, there is a clear environmental disturbance that is interrupting sleep.
Here are some of the external sleep interruptions I’ve heard of over the years:
– a snoring, or moving, bedpartner who may have a sleep disorder of their own
– bedpartner who gets into bed later, or who gets up earlier, thus waking up the person experiencing insomnia
– dog’s collar jingling
– cat asking for attention by scratching on the bedroom door
– outdoor lights that turn off and on with movement (hate those!)
– children in the bed, snuggled right up against the patient who then is uncomfortable
– an appliance or toy that beeps
– the cell phone, often a problem when it is used as an alarm clock
. . . and the list could easily go on.
When you are working to improve your sleep, you first want to eliminate as many of these interruptions as possible. I recently was working with a woman struggling to sleep well, waking 2-4 times each night. When asked “what wakes you in the night” she identified that sometimes her husband’s snoring woke her. We dialed down into that a little more, and she estimated that his loud snoring is responsible for half of her wakings, and realized looking back on it that when he’s away she does sleep better. Another person, a mother, said that she’s often squished between her children during sleep, and has no sleep problem if she has the bed to herself.
When you are working to improve your sleep, a helpful first step is to see if any external factor is interrupting or preventing you from sleep. Systematically resolve those interruptions, and then re-assess. You may find that those interruptions you were tolerating are not so trivial!
In my office, people who are taking many sleep medications for long-term use often come in looking for alternatives. In naturopathic practice there is a place for medications in the ‘Therapeutic Order.’ In naturopathic medicine the ‘least force’ treatment is used which will be effective. For instance, behavioral medicine will be used for insomnia first. Of course, behavioral strategies may not work for each person, so then herbal or nutrient therapy may be used next, and then pharmaceuticals.
Recently a person came in who had been using a combination of four sleep medications over the last 10 years. He had been alternating the medications on his own schedule as they became ineffective, and to avoid the need to increase dosage. Here was his regimen:
Alprazolam (Xanax) at 4am at his early am wakening to get another 3 hours of sleep. Alprazolam is a benzodiazepine hypnotic. Side effects include an increase in depression. When stopping the medication rebound insomnia can occur. Most of the hypnotics should not be taken with alcohol.
Zolpidem (Ambien) or Eszopiclone (Lunesta) Both are non-benzodiazepine hypnotics. Ambien is long-lasting, and people should be sure to have a full 7-8 hours in bed after taking it. Lunesta is one of the few medications approved for use on long-term basis.
Clonazepam (Klonopin) which is a long-acting benzodiazepine.
Even with these medications he was having interrupted sleep and found his sleep to be unrestful.
Our approach was to first use behavioral strategies to make his sleep robust and restful. Once he was sleeping well, we designed a schedule in collaboration with his PCP to taper down off the medications slowly. In this way we were able to avoid rebound insomnia and other withdrawal symptoms.
So, if you are struggling with insomnia, use the ‘least force’ treatment strategy that will solve your sleep problem. If you are recommended a sleep prescription, find out how long that medication can be safely used, any drug interactions to be aware of, and the typical withdrawal symptoms.
There are many ways a person could experience insomnia. It could be difficulty falling asleep at the beginning of the night, or being awake for an extended time in the middle of the night, or waking too early.
Whatever time it is, being awake in bed can often lead people to feel frustrated, angry or hopeless about their sleep. As you can imagine, these feelings do nothing to help a person fall asleep. Let’s talk about some strategies to use to help yourself fall asleep.
An ‘Over-active’ Mind
Frequently people tell me that their mind is going a mile a minute once they are awake in bed, that they have ‘buzz brain.’ In this situation, you want to establish boundaries with yourself that bedtime (from lights out to wake time) is not a time to think things through.
So first of all, schedule time 2-3 hours before bed to jot down the thoughts that arise at night, and put them to rest. Spend just 10 minutes on this, so you don’t get further entrenched in those thoughts. You can use any format that works for you – a To Do list, journal, problem and solution brainstorming list, calendar system, or any other format.
Second, if thoughts arise in the night, tell yourself that you already thought about it, and will have time tomorrow, now is time to rest. Putting your thoughts aside like this is a skill, and like all skills, you will get better the more you practice.
Follow this up with purposefully substituting thoughts that help put you to sleep. Some strategies are: a sleep promoting visualization (think dozing on the warm sand at the beach), or slow deep breaths, or repeating a prayer or mantra. For people who are also physically restless, doing progressive muscle relaxation starting with the feet can help still both the body and mind.
Almost everyone has difficulty sleeping occasionally, and these strategies can help quiet the mind and promote sleep. Establish with yourself that during your sleep time you are “off duty” from all types of thinking or planning. You will feel better for having a good nights sleep, and be better able to think things through well during the day.
The Cognitive-Behavioral Therapy for Insomnia that we offer is based upon the program developed and researched originally at Stanford University Sleep Disorders Center. In this systematic program participants first learn some basics about sleep and to re-associate their bed with sleep. Next we reframe any sleep misconceptions or worries that actually interfere with sleep. An example is “If I don’t get to sleep right now I’ll never be able to get through my meeting tomorrow.” Realistically, the person who struggles with chronic insomnia has probably gotten through demanding days in the past after a disrupted night. While doing this cognitive work to reduce worries, we also teach relaxation techniques to relieve body tension that can contribute to insomnia. Another key component of our program is sleep restriction therapy. The client’s sleep diary is analyzed, and a agreeable bedtime and waketime set. As the client’s sleep improves, and they no longer have much (if any) time lying awake in bed, the bedtime is incrementally advanced each week. This process continues until the person reaches the goal – feeling well rested each day, and having consolidated sleep each night!
What makes our approach to Cognitive-Behavioral Treatment for Insomnia naturopathic is that we know the person’s health is an entire system, that their sleep can not be separated from the entirety. In addition to factors that conventional sleep specialists evaluate, we will also assess food allergies / intolerance, neurotransmitter levels, and overall wellness. Therefore we begin the program with an extensive intake interview. During this initial intake we review the clients’ health in all areas that have relevance on their sleep. This includes neurological, endocrine, psychological, and lifestyle, among others. We may also order lab tests to evaluate organ function. Our goal is to first identify the underlying cause of the sleep disorder, then to treat. Wherever the original cause lies, chronic insomnia has developed over time as an interplay of predisposing, precipitating and perpetuating factors, which will take time to tease apart and heal.
A couple weeks ago a pilot study was published looking into tart cherry juice for insomnia. Here’s a few details:
15 older adults who have chronic insomnia but are otherwise healthy drank the cherry juice blend twice a day for 2 weeks. They kept a sleep diary during this time and during another 2 week time.
The results showed that on the cherry juice they had less time awake in the middle of the night. Tart cherry juice contains naturally occuring melatonin, which is thought to be responsible of the effect. The authors state that this was a mild effect, and that cognitive-behavioral therapy and pharmaceuticals have a larger effect on insomnia.
So what’s our conclusion? At this point in time, you could try tart cherry juice, but if you have significant insomnia, other treatment methods will be more successful.