Note: This is a short book I wrote in 2011/2012. Most of this stuff is still very relevant, but you'll notice a couple of chapters are missing (guess I didn't save often enough). Also note that the Zeo company went bankrupt shortly after I published the book.
CHAPTER ONE
Sleep Defined
“In animals, sleep is a naturally recurring state characterized by altered consciousness, relatively inhibited sensory activity and inhibition of nearly all voluntary muscles. It is distinguished from wakefulness by a decreased ability to react to stimuli, and it is more easily reversed via stimuli than the state of hibernation or of being comatose.
During sleep, most systems in an animal are in a heightened anabolic state, accentuating the growth and rejuvenation of the immune, nervous, skeletal, and muscular systems. Sleep in non-human animals is observed in mammals, birds, reptiles, amphibians, and fish, and in some form in insects and even in simpler animals such as nematodes, suggesting that sleep is universal in the animal kingdom.
The purposes and mechanisms of sleep are only partially clear and the subject of substantial ongoing research. Sleep is sometimes thought to help conserve energy, though this theory is not fully adequate as it only decreases metabolism by about 5–10%. Additionally, it is observed that mammals require sleep even during the hypometabolic state of hibernation, in which circumstance it is actually a net loss of energy as the animal returns from hypothermia to euthermia in order to sleep.”
This next bit applies only to mammals and birds. I assume you’re a human being reading this because we share the same stages of sleep as these two. Reptiles, fish, and amphibians experience sleep differently, so they’ll have to provide their own author and do their own research. I really don’t care how a snake sleeps.
Sleep is divided into three broad categories:
- Awake - because you do wake up during sleep, even though you might not be aware of it.
- REM or Rapid Eye Movement sleep.
- NREM or Non-Rapid Eye Movement sleep (how creative!!)
Just to make things more interesting, the sleep research community has further broken down the NREM portion of sleep into N1 through N3. This “N” designation simply represents “Non-REM”.
I wouldn’t even bother you with this, but these N’s come up all the time in more technical conversations of sleep - and I assume you might need some fascinating dinner conversation sometime.
Note that, until the late 1980s, there was also an N4 stage. This has recently been combined into N3. So if you ever see it, here or elsewhere, read it as N3.
This diagram shows how a typical, average night of sleep looks (although I’m not sure there is such a thing as a typical night).
This graphic is from the Zeo Sleep Management System, which is basically a single channel brain-wave monitor (EEG) that you can use at home (I used one).
Some observations about this Zeo graphic:
- You wake up during the night - even if you don’t realize it (notice the highest bars).
- Most of your Deep Sleep is front-loaded; your body craves that first (the lowest bars).
- REM Sleep usually occurs later in your sleep cycle.
- Light sleep is scattered all through the night - and makes up the majority of the sleep that you get.
All throughout this book, you’ll see references to the Zeo Sleep Management system. It’s what I primarily used to measure my own sleep.
It had the benefit of being the only consumer-available sleep monitor that actually measured the electrical activity in your brain, so it could accurately determine which phase of sleep you were in (light, deep, REM, awake). Most of the other devices (apps) simply measured body movement during the night - good but not great.
Zeo even went so far as to publish data comparing their monitor with professional sleep studies (polysomnography). Their data showed that the Zeo was in the same league as the pros.
Unfortunately, there were too few sleep-geeks out there willing to shell out the money for the device, and the marketplace spoke. Zeo went out of business in May 2013.
While there will always be new players in the sleep measurement space, the EEG (brainwave) monitors available to the consumer are not easily found - and I haven’t tried any yet.
Stay tuned to the BuildBetterSleep blog to see if that changes…
The first major category to cover is wakefulness – being awake. You’ll notice that this happens a few times a night (refer to that diagram) – and this is very normal. As you go through a normal sleep cycle – typically around 90 minutes to go through all the stages – you go through periods - usually a couple of minutes or less - where you are fully awake. We normally wake momentarily whenever we change position in bed. It’s generally thought that if you wake for less than five minutes, you probably won’t remember it.
**An interesting side-note to this is that researchers now believe that many sleep medications don’t actually make us sleep more - they act to make you forget all the times you were awake during the night! See the section on benzodiazepines.
REM sleep is where most of our dreaming occurs, whether we remember them or not. It’s characterized by the rapid movement of the eyes underneath your eyelids (it’s further classified into tonic and phasic, but I don’t really think that matters here).
As mentioned earlier, REM normally occurs later in your sleep – toward morning, and generally occupies 20-25% of the total time you are asleep. During REM, your major muscles (arms, legs) are paralyzed or frozen – we’re not exactly sure why, but logic suggests it’s so we don’t “act out” our dreams. When this paralysis is messed up (either no paralysis during REM or paralysis outside of REM), it presents interesting sleep problems - like thrashing about in bed without knowing it. Note that most parasomnias occur during deep sleep (N3) not REM sleep.
REM is thought to be the time of the night where we consolidate memories and learning - think of it as the mental repair portion of your sleep. This is the time we discard unimportant thoughts and reinforce significant ones.
The other broad category of sleep is Non-REM. When you see a reference to N1, N2, or N3 sleep (and now that you’re a sleep expert, you will), this is what’s being talked about. During any of the NREM stages, the body isn’t paralyzed, and there aren’t any rapid eye movements. Dreaming happens, but it’s rare. Again, these stages are pretty easy to identify if the subject’s brain-waves are monitored with an EEG or a device like a Zeo.
N1 is the first stage of Light Sleep. This is when we go from “restful consciousness” to the very beginning of a sleep cycle.
You are easily awakened during N1- in fact, people that are aroused from this state believe they’ve been awake the entire time. If you’ve ever experienced a sudden, jerky movement of parts of your body while you’re falling asleep – it’s this N1 stage you’re experiencing (and it’s completely normal). If you ever forget whole sections of that TV program you were watching - you may have been in N1 sleep.
N2 is also considered Light Sleep - it’s just a slightly deeper stage. This is where we start to see “sleep spindles” and “K-complexes” in our EEG’s (out of the scope of this short book). N2 is identified by these EEG phenomena. It’s also very easy to be awakened in this stage, and dreaming is rare.
N3* is what we call Deep Sleep. Sometimes this is called slow-wave sleep, as the EEG recordings show a real slow-down of your brain-waves as you progress through the different stages (N1-N2-N3). If you're going to dream outside of REM sleep, N3 is likely where it will occur. It’s during this phase where most parasomnias like sleepwalking, night-terrors, and teeth grinding will occur.
Waking a person up from N3 is much more difficult than from N1, N2, and REM. If they are woken (like with an alarm clock or a fire alarm) and they were in N3, they will be groggy and unfocused for quite a while (this is how the “smart alarm clock” Smartphone apps work – they look for an easy-to-wake state like REM (there are a couple of ways to do this) and announce an alarm during this phase).
N3 sleep seems to be really important because your body will make sure that it gets this kind of sleep at the expense of any other. REM can suffer, N1 and N2 can suffer, but you’ll almost always get the minimum N3 that you need. You’ll notice that the deep sleep – N3 – will normally occur early in the night where there’s the best chance of getting enough of it.
Remember when your grandmother would tell you that “your best sleep comes before midnight”? She didn’t know why - but now you know … it’s the N3!
N3 is thought to be the time of the night where your body does it’s physical repair jobs - mending muscles, bones, and organs. Nobody is really sure of the function of N1 or N2 - other than rest and relaxation.
*Remember that until the late 1980s, deep sleep was divided into N3 and N4, but they are now consolidated into N3.
Each of the different sleep phases (Awake, N1, N2, N3, and REM) corresponds to a particular type of brain activity. We can measure that brain-wave activity pretty accurately, and that is in fact how a device like the Zeo (or a sleep lab’s EEG) converts brain frequencies into known sleep states.
The actual frequencies of interest are:
- Alpha Waves - 8-13Hz
- Beta Waves - >13Hz
- Theta Waves - 3.5-7.5Hz
- Delta Waves - <3hz li="">
*Note that Hz stands for “Hertz” and is the name we give “Cycles per Second” of frequency. Your normal household power is 60Hz (and quite a bit more powerful than a brain-wave), but these brainwave levels are very, very low in comparison.
Each waveform corresponds to a known level of sleep:
- Awake: Primarily Beta waves with no particular “structure”, mixed with some Alpha waves. There’s lots of complicated brain activity going on when you’re awake (as you would imagine).
- Falling Asleep (N1): Reduced Beta activity, more Alpha waves - also seen with meditation and relaxation techniques.
- Light Sleep (N2): Mostly Theta waves.
- Deep Sleep (N3): Mostly slow Delta waves (this is why it’s often called SWS - Slow Wave Sleep).
Our bodies follow a natural rhythm from day to day. There are physical, mental, and behavioral changes that roughly follow a 24-hour clock - and they respond mostly to light and dark (sunlight and night-time). As much as we might want to influence them, these are major forces at play that are tough to override. These drivers include:
- The Sleep-Wake Cycle
- Body Temperature Control
- Hormone Production
- Digestion
- Many others
It’s important to note that some of our “routines” are embedded in our DNA, and we function best when we work with these rhythms, not against them.
Suffice to say that there is a daily rhythm that your body naturally goes through, and we call it the “circadian rhythm”. You’ll hear that term a lot when you research sleep.
There’s another circadian indicator for sleep, and that’s our body’s release of the hormone melatonin.
Melatonin is chemically known as N-acetyl-5-methoxytryptamine, and it occurs naturally in most plants, animals, and microbes.
In humans, it’s a product of the pineal gland in the brain, where it is manufactured from the chemical tryptophan (the same stuff you find in your turkey dinner or a glass of milk).
In mammals, melatonin production is triggered by darkness (night-time), and stopped by light (morning). This is why it’s known as the darkness hormone, and why it’s an essential component of our circadian rhythms.
Supplementing with melatonin is a common way to influence your sleep - with varying degrees of success.
One of the most frequently measured circadian rhythm in our lives is the daily ebb and flow of body temperature.
We’ve all been told that it’s supposed to be 37C (98.6F), but that’s only an average. It actually varies from about 37.5C (between about 6am and 10pm) to 36.5C (between about 2am and 6am).
There’s two obvious points in the day when our temperature drops: shortly before bed at night, and shortly after noon.
A low body temperature is an indicator that “it’s time to sleep”, so this is when you start to feel sleepy. The bedtime drop is obvious, but so is the after-lunch drop - you feel tired in the early afternoon. It’s called a siesta in many cultures, and it’s built into their day. Maybe they know something we don’t.
*Enlightened businesses these days are introducing “siestas” into the work day - they find productivity goes up if people are allowed a short nap after lunch.
Sleep is a very individual thing, and all anyone can really give you are generalizations about how much you need.
We tend to sleep less as we get older – some say this is a function of age, and some say this is a function of activity (mental and physical). Some even report to sleep better as they age - perhaps less stress?
We know that infants sleep a lot, and they have extraordinarily long REM sleep sessions during their slumber (consolidate learning, anyone?). As teenagers, it changes with a desire to stay up late and sleep till noon. As adults, it changes even further. It seems that the best judge of your sleep is you. How do you feel in the morning? Is 7 hours of sleep good for you, or do you need 9 to feel really rested?
If you can you easily sleep in an extra few hours on the weekend, it probably means that you could stand to get some extra sleep during the week! Current recommendations for adult sleep are between 7 and 9 hours - and I would suspect most of us should fall somewhere in there.
You’ve heard stories of people that get by on 4 or 5 hours of sleep a night. People that can truly thrive on this amount are very rare ... it’s far more likely that the 5 hour sleeper is really sleep deprived.
Maybe more important than the total amount of sleep you get is amount of each type you get - read on…
Sleep pressure is simply the build-up of tiredness that accumulates during our waking hours. It starts off very small (ever try to take a nap in the morning after a good night’s sleep) and builds up during the day.
Sometime later at night, the pressure is such that we feel tired. This feeling is generally much stronger than the one we might feel during the day (commonly after lunch - the siesta).
Over time, if we’re awake long enough, this sleep pressure is hard to resist - our body tells us that it has to get some sleep. One of the most potent forms of treating insomnia is to utilize and exploit sleep pressure (more on that later).
Sleep deprivation is best described by how “normal” you feel the next day. Are you tired, unfocused, lethargic, uncoordinated? These can all be symptoms of not enough restful sleep. For some, it’s an actual medical problem – insomnia. For others, it’s a scheduling problem – not giving yourself enough time to actually sleep.
Regardless, long-term sleep deprivation has some fairly serious health consequences – heart attacks and strokes are among them. So it’s in your best interest to address any deprivation issues you might have.
If it’s insomnia, find out and treat the root cause if you can (I assume that’s why you’re reading this).
If it’s scheduling time to sleep, find a way to manage your calendar!
We’ve finished our sleep primer, so I though this may be a good time to throw in a small tangent. I want to show you some overarching “sleep themes”, and how powerful your body really is, even when it’s “broken”.
I’m a textbook insomniac, but even with my sleep issues (shown in this graphic), there are some fundamental mechanics that still hold true.
- I believed that I had no sleep at all – but I did (about 6:02 of it). I was absolutely sure I was awake all night!
- I got N3 (deep sleep) the first part of the night - 45 minutes worth. That’s about average for someone my age.
- Most of the REM (1:55) came later in the night. Again, an average amount of REM too.
- My sleep cycles are all messed up – the frequent awakenings are the main symptom of my insomnia. Normal awakenings/night for someone my age is 4 - mine is around 15. This is where my particular problem lies.
None of this is to say that your insomnia cannot be a type that overrides these underlying rhythms, but that it’s rare - it takes a lot to break some of these basic sleep patterns.
CHAPTER TWO
Insomnia
Although there are variations of this theme, insomnia is generally regarded as a “yes” answer to either of these questions:
- Do you have difficulty falling asleep at night?
- Do you have difficulty staying asleep at night?
A complete diagnosis needs to include a third question - one that a sleep specialist would likely ask:
- How do you feel and function the next day?
This third question is as critical as the first two. You don’t have textbook insomnia if you believe you don’t sleep at night, but seem to be just fine the next day.
It’s been shown that people are very poor perceivers of their own sleep (ie: they believe that they “got no sleep last night” when a polysomnigraph shows that they slept for 6 hours)!
I believe that if you can’t actually measure the insomnia (hard without some instrumentation), the next-best estimation would be how you feel the next day - are you unfocused, tired, irritable, angry, lethargic? Any other indicator that you’re not yourself?
Some people can function fine on limited amounts of sleep (Round-The-World Sailors), but most really suffer with it. The effects of insomnia are basically an inability to function normally. They may hallucinate, have difficulty doing simple tasks (like driving or cooking), experience day-long tiredness – generally ruining their quality of life.
It’s quite normal to experience a few days or a couple of weeks of poor sleep once in a while. Often, it’s brought on by a psychological or physical trauma of some sort – a death in the family, a bankruptcy, a looming deadline, ongoing pain – anything. Once the event passes or the shock wears off, the sleeplessness goes away. We’d call this transient or acute insomnia. If it lasts much longer than about a month, we transition into chronic or long term insomnia.
So, now that we’ve defined insomnia, it’s important to differentiate between the two types – primary and secondary (sometimes called co-morbid).
For reasons that will become obvious in a moment, we’re going to cover Secondary Insomnia first.
Secondary or Co-morbid Insomnia is brought about or amplified by a mitigating medicine, medical issue, substance or behavior. In fact, secondary insomnia sometimes is additive to and masks a primary insomnia - in which case you have two different insomnia types to figure out.
Secondary Insomnia can have hundreds of sources, and is the most common type of sleeplessness (as high as 80% of all insomnia cases). It’s important to closely look at any of the possible factors that could be the root of your insomnia. Common ones would be:
- Sleep Apnea - this is a medical issue that is treatable. Once you manage the Sleep Apnea, the insomnia will likely take care of itself. Pay special attention to loud snoring - it’s a common sign of sleep apnea. Most often sleep apnea is first noticed by the partner, spouse or parent.
- Medication - This could be a prescription or something you take over-the-counter affecting your sleep. I’d recommend a chat with your pharmacist to see if anything you’re taking could be the source of your insomnia. It’s a common side effect of many medications.
- Caffeine - Many people are sensitive to the affects of caffeine, and caffeine is hidden in all kinds of food and drink - coffee, sports drinks, chocolate, some teas - it’s a long list. Even if you cut off all caffeine at noon, there might still be enough in your system to affect sleep at night. It’s best to try weaning off it completely for a few days or weeks to see if your sleep improves. If it does, then you can slowly reintroduce it earlier in the day to see at what time it starts affecting sleep again.
- Chronic Pain - Pain of any kind can keep you awake at night. Manage the pain, and you manage the insomnia. Be careful with the pain management though - it could add a source of insomnia (become friends with your pharmacist)!
- Menopause - Hot Flashes at night are called “Night Sweats” and will keep you awake, tormenting you at the worst possible moment. While HRT is very controversial, there are a number of more natural or holistic ways you might manage (basic sleep hygiene sometimes does the trick). Do some research on-line and see your doctor.
- Restless Leg Syndrome - If you have uncontrolled, spontaneous movement of one or both of your legs as you lie down to sleep, you may have Restless Leg Syndrome. Until the movement settles down, restful sleep is nearly impossible. Talk to your doctor about it - there are treatments.
- Drugs - While some say that drugs like marijuana are sleep-inducing, studies have shown that they have the opposite effect in many people. The same could be said of most drugs. They could easily be the cause of your insomnia.
- Snoring. No, not yours - your partners. Your insomnia could be an inability to sleep with the noise. Try earplugs or another room.
There could be many, many more roots to your sleep issues - so it’s important to investigate this angle thoroughly. Keep that 80 percent number in mind. Talk with your doctor and your pharmacist. Make sure that there’s nothing that you consume, no environment that you live in, and no manageable condition that you have, that’s at the bottom of this problem.
It would be tragic to suffer with insomnia for months or years only to discover that you’re intolerant to coffee after 9am in the morning…
One last time - upward of 80% of all insomnias have some other condition at their root. You can try to cure insomnia all you want, but if you fail to tackle this other issue, all your efforts will be in vain.
Primary insomnia is the condition you’re left with when there is no medical, environmental or psychiatric source of the sleeplessness (any Secondary or Co-morbid cause).
Sometimes it’s a fine line - maybe your insomnia is related to depression, but the depression medication that you’re taking is causing additional insomnia. So the cure of one condition is the source of another. Maybe juggling medications with help from your doctor can manage both the depression and the insomnia. Investigate everything thoroughly!
Other times there just isn’t an obvious treatable condition. That’s the camp I find myself in.
The root of most primary insomnias is in your brain and we have to re-train ourselves to sleep.
There are several paths to investigate when resolving a primary insomnia, and we’ll touch on the most common of these in the next couple of sections.
Because I live in Canada, these stats are from a 2002 Canadian study. I’m sure there is similar research, with similar stats, in the USA and Western Europe (and I now understand that large parts of the Third World, as they become more “westernized”, suffer these same statistics too). Since these stats are dated, you can safely assume that insomnia has worsened, not gotten better:
- 13% (about 1 in 7) of people over the age of 15 have insomnia – defined as a hard time either getting to sleep, a hard time staying asleep, or both. This “getting to sleep or staying asleep” was the question they asked – and those that said “most of time” or “all of the time” were the one’s considered insomniacs. The rest of the study focuses on this group.
- 18% of these insomniacs reported sleeping less than 5 hours a night.
- 29% of them said that they had taken some kind of sleep medication during the previous 12 months (versus 7% of people who fall out of the “insomniac” camp).
- Medical conditions like asthma, arthritis, diabetes and back problems seemed to affect about 20% of the sleepless.
- Almost a third of people reported insomnia along with their anxiety or mood disorders – versus about 12% who didn’t report these anxiety/mood issues.
- 23% of people who reported their lives as “stressful” suffered from insomnia – about double the people who reported “little or no” stress.
- 16% of heavy drinkers reported insomnia. Alcohol may help you get to sleep, but the quality of that sleep is really poor.
- 18% of people who use cannabis (marijuana) were sleepless.
- Heavy/obese people have a higher prevalence of insomnia than people of normal weight. This may be linked to sleep apnea, but this wasn’t investigated. The lowest reported episodes of insomnia were people of a normal (not too low, not too high) weight.
- Insomnia rises with age – about 10% at age 15-24, to about 20% at age 75 or older.
- Women are more likely to report insomnia than are men – 15% versus 12%.
- There seems to be a socio-economic angle to this too – those with high school education or less report a higher incidence of insomnia than the more educated groups. Lower education generally translates into a lower standard of living (they looked at this as well) and poorer sleep.
- 17% of insomniacs rated their ability to cope with difficult (family or personal) problems as fair or poor. 8.5% of those without insomnia answered the same way.
Besides insomnia, there are several issues around disturbed sleep that don’t neatly fit into any category. These next few chapters will talk about treating insomnia, but after that there’s a special section on some of these specific sleep-related phenomenon:
- Sleep Apnea
- Nightmares and night-terrors
- Sleep Walking
- Narcolepsy
- Jet Lag
- Bruxism
- Circadian Rhythm Disorders
CHAPTER THREE
Using Your Brain - CBT
One of the most basic (and one of the most successful) of any kind of insomnia management is to change the way that you think about insomnia.
“Cognitive Behaviour Training” (CBT) is an acronym for “reprogramming yourself to think and act differently about sleep”. CBT is what we do whenever we change things on the psychological level, and don’t rely on drugs or supplements to aid in your sleep.
CBT can include parts or all of:
- Journaling
- Sleep Hygiene
- Relaxation and Meditation
- Feedback (biofeedback)
- Sleep Restriction
CBT involves a few simple steps that are common among all variations of an insomnia program. The first, and most important of them is a good understanding of sleep itself. Reading this book is a great start to this education, and it might be all you need, but it’s still a good idea to research sleep broadly so that you have a good, solid understanding of what’s going on. Read lots - as a matter of fact, reading my blog is a good start.
The second step is journaling. It’s important to know where you’ve been and where you are now. By knowing what that path looks like, you can make further decisions about your sleep going forward. We’ll mention journaling several times in the coming pages.
The third step in our list is to reprogram the way you think about sleep.
At it’s fundamental level, CBT is about changing your attitude. How often do we lie in bed at night and say to ourselves:
- “Why can’t I get to sleep?”
- “I need to get to sleep in the next ten minutes”.
- “I’ll be a wreck in the morning if I don’t get some sleep”.
- “If I don’t get enough sleep, I’ll get sick”.
- “It’s 2:30am and I’m still awake. I’m doomed”.
- Any other negative chatter about the sleep we’re getting (or actually, the sleep we’re not getting).
The trick is to train yourself to think much more positively about your sleep. When you do this for long enough (a few weeks), you’ll find that those negative self-fulfilling attitudes are starting to change into positive self fulfilling ones. Try changing these thoughts into positive statements like this:
- “One or two nights of missed sleep is not that important”.
- :I’m probably getting lots of sleep, I just don’t realize it.”
- “Just laying here and relaxing is good for me”.
- “I will not get sick from lack of sleep”.
- “No matter how much I sleep, tomorrow will be a good day.”
You will probably catch yourself thinking negative thoughts about your sleep. When you do, write them down, think about them for a minute, and then write down the positive opposite of that negative thought.
Whenever that negative thought enters your mind again, consciously replace it with the positive one. Do this enough times, and the negative thoughts go away completely.
We all know that often it’s this incessant background “mind chatter” that causes a lot of our sleeplessness.
A very simple step that reinforces this cognitive control is to move the clock in your bedroom so you can’t see it. Constantly “clock watching” reinforces all those negative thoughts.
If this simple exercise works for you, than you can forget the rest of this book - you’ve just solved your insomnia. For everyone else, let’s charge into some journaling and Sleep Hygiene…
Before we dive into treating insomnia, there’s a very basic technique I would recommend using so you can better quantify the problem you actually have.
Start a sleep journal.
The most basic of sleep journaling is as simple as leaving some paper by your bedside so you can write a few lines first thing in the morning. You'll want to log a few simple variables:
- Yesterday’s date (the night-of ___).
- What time you went to bed.
- Guess the time you fell asleep (don’t watch the clock!)
- What time you woke up and got out of bed.
- How you slept the night – maybe on a scale of 1-10.
- Any other variable you'd like to track – like number of times awakened, whether you had a hot bath, loud noise from the street, whatever.
Do this for a couple of weeks, and if you notice a pattern of sleep (bad or good) that tells you something. Maybe your problem is falling asleep. Maybe, like me, it’s several awakenings during the night. Maybe you find that the earlier you go to bed, the worse your night ends up being.
The journal can be a window into your world at night - something that most of us take for granted - but if you have trouble sleeping, it can be a treasure trove of useful information.
If you're anything like me – the data you gather by writing things down is a small subset of what you’d like to know. I have about twenty variables that I want to track, and it's all but impossible to do with a pen and paper - and even if you did, seeing a trend would be very hard.
What I do is log everything in an on-line spreadsheet every morning. I make it easy to graph by using 1’s or 0’s (or whole numbers if it’s a scale like quality of sleep) - and I can infer a lot of information once the spreadsheet has been turned into something I can visualize - a graph.
Whether you choose to use a spreadsheet of your own, or default to one provided for you, the data you have access to analyze is incredibly revealing.
For most people that suffer with insomnia, “Sleep Hygiene” will be a new foundation they incorporate into their nights. And for good reason.
The idea behind Sleep Hygiene is to retrain your brain to know when and how to sleep (and include it under the banner of CBT). The way to do this is to remove any potential sleep obstacles, and then establish a pattern for sleep that your brain will understand - you are building a new set of habits.
Whether you are consciously aware of it or not (likely not), your brain will pick up on these changes you’re making. And if you make them for long enough, it will start to expect them, and react accordingly. This is building sleep as a habit. Follow these guidelines as best as you can:
- As we mentioned back in Journaling, keep a journal. A scrap of paper or a spreadsheet, it doesn’t really matter. Just as long as you record what you’re doing, and what effect it has on your sleep. Otherwise you can’t tell what’s working and what’s not.
- Further to the journal, try to make only one change at a time. Give it a week or two, and see if it’s made a difference. Regardless of whether it has or it hasn’t - incorporate another change. Often, it’s not a single change that makes a difference, it’s a combination of changes. The journal can help you discern what and when you changed. Know that solving your sleep problem will take time - there is no “quick fix” to this one…
- Get up and out of bed at the same time every day. Weekends included. This might seem silly, but it’s one of the most basic ways of reprogramming your brain. If you feel you have to sleep in on the weekend, make sure it’s no more than an extra hour in bed (your brain will likely grant you this much latitude). If you go to bed extra late one night - get up at the regular time the next morning regardless. After a while, you’ll find yourself unable to sleep in (that’s where I’m at now).
- Just like getting up at the same time, go to bed at the same time every night. This one is a bit tougher to manage, but do it if you can. Train your brain to expect bedtime. Don’t make the mistake of setting bedtime too early and expecting to sleep!
- Your bed should be for sleeping and sex only. Your brain should associate the bed with only these two things. No reading, no watching TV, no working on that report, no surfing the Internet on your iPad, nothing. It’s into bed and lights out. This is another integral part to CBT and reprogramming. Bed means sleep (or sex!).
- Make your bedroom a place of refuge. We sleep best when the room is cool, and we’re warm (but not hot) under a blanket. We sleep easiest when it’s dark and quiet. We quiet our minds when the room is orderly and there’s not a lot of junk lying around. So make your room this way. Make it cool, dark, quiet and neat. Do whatever it takes - a white noise generator for a noisy street, tinfoil on the windows to block out light from a street lamp, and earplugs to block out noise from outside. Again, do whatever it takes.
- Remove the clock - or at least turn it toward the wall. There’s nothing more frustrating than to glance at a clock at 3am, and worry about your sleep. Make it difficult for you to do. If you need the alarm to wake up, face the clock away from your line of sight at night.
- Avoid any strong artificial light within an hour of going to bed. This means no TV, no Smart-phone, no Computer, no iPad, nothing. These devices all produce blue light, and that triggers your brain to think that it’s morning, not nighttime. If you have to read before bed, chose something that’s not back-lit (a B&W eBook or an old-fashioned book works well). Turn the lights down lower throughout the house, too.
- Further to the electronic appliances (TV’s and computers of all types), in addition to the unwanted light they produce, they cause unwanted brain activity - the kind that you don’t want when you’re getting ready for bed. Even if you don’t realize it, they’re causing your brain to “ramp up”, not “ramp down”. An exciting book (a thriller?) can do the same thing.
- Get some exercise every day - 30 minutes or so should do it. This may mean a walk or a bike-ride, but your body craves movement, so move! More exercise is linked to better quality sleep. Avoid vigorous exercise too late in the day (say, past 7pm) - your body temperature rise will make it harder to fall asleep.
- Avoid anything confrontational at night. Bedtime is the wrong time to have an argument with your boss or your wife (which may be the same person!). The extra emotion and anxiety you bring to bed with you is almost guaranteed to effect your sleep.
- Make your bedroom a no pets zone. Whether you realize it or not, a pet on the bed, or in the room anywhere, can be very disruptive. Even when you think they have no affect on your sleep, they probably do. Pet dander can cause allergies, and their movement at night can wake you up - even if you’re not aware of it. See if there is some way to make them comfortable elsewhere in the house where you cannot hear them as they move around during the night.
- Try a hot bath before bed. Paradoxically, the rise in your body temperature from the bath will amplify you body’s natural lowering of body temperature at bedtime. Time it so the bath is about 1.5 - 2 hours before actual bedtime.
- Establish a night-time routine so that you can teach your brain to “expect” sleep. Note that turning off the TV and computer should be part of this routine. Again with the brain – the intent is to teach it that there’s a ritual of sorts that we go through every night, so it can associate this ritual with going to sleep. Make sure that part of your routine includes turning down the lights as you approach bedtime – it’s night!
- Get some sunlight in the morning – wake up and open the drapes or blinds and stand there for a few minutes. Eat your breakfast by a window that gets direct sunlight. If it’s dark and gloomy where you are, invest in (or make) a light-box. Note that your average living room’s light level is about 50 LUX. The average office can be up to 300 LUX. Sunlight can be up to 130,000 LUX!
Although these tips and techniques sound daunting, they’re really not. Aim for 100% compliance with all of them, and if you manage to hit 85 or 90% compliance, you’re a superstar!
Napping is one of those controversial aspects of your sleep. Do it too much, and you lose any “sleep pressure” that you’ve built up for that night. Don’t do it at all, and you’re tired and lethargic for much of the afternoon and evening.
Here’s what I propose, and current conventional wisdom is:
- Napping is perfectly OK.
- Nap early in the afternoon - before 4pm.
- Keep your naps short - 10 to 30 minutes max. What can happen is that you can fall deep asleep if you nap too long, and that will cause you to wake up groggy, and probably affect your sleep that night.
- If you keep the nap short, it’s surprising how refreshed you’ll feel. Even 10 minutes without any noticeable sleep makes a huge difference (again, me as an example, I never fall asleep but always feel surprisingly refreshed after laying down for 20 minutes in the early afternoon).
For that out-of-date advice that if you have sleep problems you should never nap, I say it’s just that; out-of-date.
This is one of those techniques that can be used when nothing else will work. After you’ve given sleep hygiene a real try (I’m thinking months, not days), you might want to give this a go.
Sometimes reprogramming your brain to sleep takes a significant “reset” to do. That’s where sleep restriction comes in. Here’s how it would work:
- Calculate (using your journal) the actual amount of time that you are asleep in bed at night - not the amount of time you’re in bed. Let’s use 6 hours as an example (Set 5 hours as the absolute minimum amount of time to restrict your sleep to - if you only sleep for 4.5 hours, use 5 hours regardless).
- Based on this 6 hours, restrict time in bed to 6 hours for two weeks. If your wake time is 7am, this would mean going to bed at 1am and getting up at 7am. Regardless of how you feel, or how well you slept, stick to this schedule. Chances are you are very tired by the time 1am comes around. It will be really hard to stay awake. Make sure you get up at 7am!!
- After two weeks, you should be sleeping soundly for most of the time you’re in bed. If not, go another week. Keep at it until you are regularly falling asleep (and staying asleep) at 1am.
- When you’re sleeping well, give yourself an extra 15 minutes in bed for another week. This means (using our example) going to bed at 12:45am, and getting up at 7am.
- Every week where you sleep well through the time in bed expand the time another 15 minutes. You’ll slowly be moving bedtime earlier in the evening.
- At some point (hopefully around the 7.5 hour in bed mark) you will stop seeing the “I’m asleep as soon as my head hits the pillow and I sleep soundly all night” mark.
- Regardless of how long you try, you just don’t seem to fall asleep at bedtime. At this point, back off the time in bed 15 minutes. This is your new sleep schedule. If you actually need 7:15 of sleep for our example, when you go to bed at 11:45pm and get up at 7am, you sleep soundly through the night. When you go to bed at 11:30pm, you just lie there and stare at the ceiling.
- By the way, if you are using sleep restriction as a method to get back to a regular sleep schedule, I’d scrap the nap. You want all the sleep pressure you can muster working for you!
For most people, this will work out to be a bedtime of about 11:30pm and a waking time of about 7am - for 7.5 hours of good, solid sleep at night.
It takes some time and commitment to do, but it works when everything else doesn’t.
In my research, whenever specialists try to cure a primary insomnia and nothing else works, they always default to this method. It takes real fortitude to implement properly, so don’t think it’s easy!!
This is another controversial one - and there’s no clear “new advice” to follow. Ask two different sleep experts about it, and you’ll probably get two different opinions.
The first camp says that if you cannot sleep within 20 minutes or so of going to bed (some say 15 minutes, others say 30), get up and go do something boring. No watching TV, but reading a book in another room, doing some light paperwork or housekeeping, or anything else mundane.
When you’re tired again (after a few minutes, hopefully), you go back to bed. The process is repeated until you fall asleep within 20 minutes of hitting the sack again. Get up at the regular time regardless of your up-and-down night. This is reinforcing the “bed=sleep” conditioning we’re trying to achieve. If you’re not asleep, you’re not in bed.
The second camp is the one I’m in - mostly because I’m lazy.
The opinion of this side of the argument is that, as long as you are calm and relaxed (that means no “background chatter” in your head), laying in bed is perfectly acceptable. It’s still accomplishing a “bed=rest” algorithm - same as napping. After a while - maybe a long while - you will fall back asleep again and you won’t be watching the clock to get up in 20 minutes if you’re not asleep. Again, move that clock so you can’t see it!
* Note that I’ve done the “get up and do something boring” in the middle of the night, and it does work. I fall asleep relatively quickly when I go back to bed…
We’ll refer you back to the section on brain-wave frequencies, to remind you of some of the prevalent waveforms to be found during sleep:
- Alpha Waves - 8-13Hz
- Beta Waves - >13Hz
- Theta Waves - 3.5-7.5Hz
- Delta Waves - <3hz li="">
There’s a science focused on affecting our brain-waves through sound, called brain-wave entrainment or brain-wave synchronization.
The thinking is, since we know that certain brain-wave frequencies pertain to certain brain states (light sleep, REM sleep, Deep Sleep, meditative states, etc), if we stimulate the brain with the appropriate tones or frequencies, we can “force” the brain to synchronize with these tones and establish the state we’re targeting.
There are two primary ways of generating these tones (they’re so low in frequency that they fall outside your typical stereo or radio):
Binaural Beats are generated by generating two tones, a few Hz apart in frequency. Each tone is “introduced” into the brain using headphones, and a “beat” tone is produce. For example, if you injected 505Hz into the left ear, and 495Hz into the right, your brain would recognize and synchronize to the “beat” between these two frequencies - 10Hz - an Alpha wave (505Hz - 495Hz = 10Hz).
Isochronic Tones are a more modern invention, where the use of headphones is not required. In this case, we generate a steady tone, and turn it on and off at a prescribed rate. Your brain picks up on the rate of this “on-off” phenomenon - maybe 10 times per second - and gives the same (most say stronger) 10Hz perception to your brain. The same Alpha wave is produced as with the Binaural Beat.
With both Binaural Beats and Isochronic Tones, the common practise is to embed the actual effect into a soundtrack that’s pleasant to listen to. The soundtrack takes you along a gentle “sound slope” from awake to asleep.
There are hundreds of tracks you can download, and a great many of them are free on the Internet. Some of the more popular Binaural/Isochronic apps are available on most Smart-phones through their on-line stores (I use ones from Pzizz, Sleeptracks and Pure Sleep).
As there’s an entire industry and centres of knowledge around relaxation and meditation, so we’ll not delve into this too deep (just Google “relaxation” or “meditation”).
Suffice to say, relaxation is the required state before anyone gets to sleep. Relaxation is the primary target in your quest for sleep - if you learn to relax, learning to sleep is not far behind.
The Binaural and Isochronic tones we just talked about can be two excellent methods of trying to induce this relaxed state. The music is calm and soothing - and has the added benefit of trying to move your brain into the appropriate state. Note that you can get specific meditative tracks with both types of these tones to help you achieve any state you’d like (reducing anxiety, meditation, alertness, etc).
Reading is another activity that many people find relaxing (just don’t read in bed - remember the Sleep Hygiene).
Meditation is a practice unto itself. Learning to meditate, breath control, controlling your muscles and your posture are all excellent. Meditation produces relaxation, and that’s where we want to be.
Practiced meditators normally never have a problem with insomnia - they can manage their brains so well, that sleep is a simple process for them. Ever heard of a monk that cannot sleep?
Yoga is a more physical practice of meditation, so it has the same outcomes - although you become more flexible in the process!
Proper meditation is the nirvana of sleep induction.
CHAPTER FOUR
Some Final Thoughts
CHAPTER FIVE
Natural Supplements
This chapter will be about some of the more popular, “folkloric” treatments for sleep. Most of them have been researched, but there is no overwhelming evidence that any of them work consistently for all people.
My best advice is that after you’ve tried all of the basic cognitive training tips, give these a go - one at a time. It may take a few days or weeks for any of these remedies to show signs of efficacy, so be patient. It’s always best to try one thing at a time, journal it, and then see if it really makes a difference for you.
If it doesn’t, scrap it and try another.
Valerian Root has long been recommended for help with sleep – both with falling asleep faster and helping you get back to sleep once you’ve woken. In fact, Hippocrates described its use in about 400BC - as a cure for both insomnia and anxiety. As with many/most “cures”, it’s controversial. Some say it works, some say it doesn’t (most scientists fall into the “no” category).
Valerian is a flowering plant native to Europe and Asia, and is now commonly grown in North America (a good photo of the Valerian plant is available on Wikipedia).
If it’s used in a pharmacological way (ie: a pill, capsule, or liquid preparation), the root is chemically separated into its individual compounds. The standard preparations will declare a percentage of “valeric acid” (the active ingredient). If it’s prepared as a tea, the root is ground up and mixed with other herbs and plants and then steeped. The tea that I use is Valerian Root mixed with peppermint, lemongrass, chamomile, and other terribly expensive stuff.
The opinions on taking the root are mixed – some say the best way is to consume a standardized amount (the valeric acid component seems to be in the 2mg-3mg range, while the actual content of the “whole root” may be 300-500mg) – and others say the best way is to drink it is as a tea.
Because of it’s purported sedative properties (most obvious with sleep), it’s also used for general nervousness, excitability, stress and hysteria. Actually, many people (doctors included) will try Valerian Root to either avoid benzodiazapines (Valium, Ativan, Paxal, etc) altogether or to assist in the inevitable withdrawal from them.
The science behind Valerian Root is where the rubber hits the road. A recent, thorough, meta-analysis (study of studies) of the sleep inducing properties of Valerian Root revealed ambiguous results. Valerian Root worked for some, but for others there was no significant, statistical difference. The researchers also determined that Valerian Root may take a few weeks to have an effect - so if nothing happens for you in the first few days, keep at it.
Personally, Valerian Root Tea did nothing for me except made me get up in the middle of the night to go pee. So, in effect, it affected my sleep - but not in a positive way. Try it though - your mileage may vary…
Kava Root has been used in the Polynesian region of the South Pacific for thousands of years. It’s used for sleep, general pain management, and achieving a state of relaxation with mental clarity.
It’s an innocent enough looking plant, but it has some interesting properties. The roots of the plant (just like it’s the roots of the Valerian plant) have sedative and analgesic effects, but still apparently allows you to be mentally alert (it reportedly doesn’t “dull” your senses - although if you’ve ever seen someone who’s taken Kava Root, I have my doubts).
Traditionally, the root of the Kava plant is ground up (either by chewing it, using a mortar and pestle, or smashing it against hardened coral), strained, and then added to cold water - to be consumed immediately.
In modern times, the roots are mechanically ground into a fine powder and then soaked in water for a half hour or so - and then strained into a drink.
Pills are made from extracting kavalactones (the active ingredient in Kava root) chemically to produce a standardized pill of between 60-150mg.
Kava root has an effectiveness of 2-3 hours (although some people report effects for couple of days), and is most like alcohol or benzodiazapine use.
As with most sleep supplements, you might find Kava root works for you, or you might not. The best case in all these instances is to give it a try.
The reported “relaxation” you feel after taking Kava root could be enough to put you over the edge into dreamland!
Chamomile is another flower that can be infused into a tea and taken to enhance sleep - reportedly because it reduces stress. Chamomile is a plant, much like a Daisy, and includes several different sub-species (wild, yellow, etc) - and they all act basically the same. Chamomile Tea is commonly available, and is taken to calm and relax as well as promote sleep. You’ll often find Chamomile mixed in with other “relaxation inducing” flowers and herbs in that tea.
This is probably the stuff your grandmother would recommend for insomnia.
Care should be taken when you take Chamomile - it can cause uterine contractions that may lead to miscarriage. The US Department of Health has advised pregnant women and nursing mothers to avoid it altogether, but it’s generally considered safe for everyone else.
Lavender really isn’t one plant - it’s 39 plants. They’re all part of the “Lamiaceae” mint family.
Lavender has several reported medical properties, and sleep is only one of them. Used in WWI as a disinfectant, it’s also used for insect bites, headaches and burns.
When used for sleep, the flower itself is infused into some hot water and the “aromatherapy” is supposed to calm and relax you. Other methods may include wrapping it in cloth and laying the bundle beneath your pillow - same effect, different strategy.
Like all of the other “natural remedies” it appears as though lavender helps you relax - which is where the sleep enhancing comes from.
Again, (this is getting repetitive) it seems to work for some people and not for others. The best strategy is to give it a try for a couple of weeks and see what happens with you.
Let’s get this one out of the way.
Alcohol is not a treatment for insomnia.
While it may cause you to get sleep quicker (ie: you pass out), it delivers a less-restful night of sleep. You’ll have more awakenings (even if you don’t realize it) and will tend not to sleep as deeply. This is what sleep researchers call “disturbed sleep”.
So the old wives tale of taking a bit of alcohol before going to bed is just that - an old wives tale.
If you want to sleep well, make sure that most of the alcohol is out of your system before you hit the sack.
This could be a very long section if I covered every natural remedy that’s reported to be good for sleep. But call me a sceptic.
The remedies I’ve listed in this section are the most common ones used for sleep - valerian seems to be the most popular - and in my research I’ve found that none of them works for everyone (and none of them really worked for me).
I’m actually starting to think that these remedies act in a whole different way - a CBT kind of way. If you truly believe they work for you - then they probably do. If you don’t believe they’ll work, they don’t work. I haven’t found a study where “double blind placebo controlled” subjects were any more affected by these remedies than by pure chance.
The net-net here is to try. Maybe, somewhere deep in your subconscious, their use is just enough to slip you into sleep…
CHAPTER SIX
Manmade Synthetics
This next chapter steps things up a bit. This book is arranged, for the most part, so that you try sleep remedies as they are presented. So, before you attempt any of these, make sure that you’ve tried Cognitive Behavior Training and Natural Supplements first. The potential side effects of a sleep remedy increase as we move through these “medicines” (remember my comments at the end of the CBT section!).
Even in this section, we’ll differentiate between substances that “occur in nature but man is synthesizing” and “don’t occur naturally at all”. You should attempt them in that order…This short list is of some of the supplements that occur naturally, but we’ve learned to synthesize. Today, the synthetic version is probably the one you’ll buy (and, in the case of melatonin, it’s the one you want!).
Melatonin is one of the most popular and available (over-the-counter in the US and Canada) drugs for people to take as a sleep aid. In addition to it’s use for insomnia, it is reported to affect maladies as diverse as delirium, fertility, migraine headaches, and cancer among several others.
Back in the 1990′s it was hailed as a wonder-drug that could cure almost everything. The hype got so out of hand that the New England Journal of Medicine in 2000 wrote an editorial that said, in part:
”The hype and the claims of the so-called miraculous powers of melatonin several years ago did a great disservice to a scientific field of real importance to human health…. Our 24-hour society, with its chaotic time cues and lack of natural light, may yet reap substantial benefits.”
There are two sleep related areas where melatonin is part of a standard therapy, normally combined with strong light (sunlight or a lightbox) in the morning. Both of these are considered circadian rhythm disorders:
- The first disorder is called Delayed Sleep Phase Syndrome, or DSPS. It’s also been known as “social jet lag”, because the symptoms are almost exactly like permanently being 4-6 hour jet lagged. The problem is most common in children and teenagers. This is where your internal bio-clock is stuck an hour or two (or in severe cases, three or four) too late – you aren’t tired enough to sleep until very late in the evening, and then you have a normal sleep until you are woken up too early for you (which is probably a normal time for most people). If allowed to sleep until rested completely, you would wake up a few hours later than most everyone else. The way this problem is resolved is with melatonin timed in the evening a few hours before normal bedtime combined with light therapy in the morning. In most cases, this will slowly synchronize the body clock with the actual one. The melatonin in this case is not used as a hypnotic sleep inducer, but rather as an internal clock changer (a chronobiotic).
- The second disorder is called Non-24-Hour-Sleep-Wake-Syndrome. This one is particularly nasty – kind of a super version of DSPS. It’s when your circadian rhythms are offset an hour or two every night, so you feel sleepy an hour later than you did last night, and wake an hour later – and this cycle goes on and on. So you finish a complete “circuit around the clock” every couple of weeks. And then it starts again. It’s as though your body takes no cues at all from the time of day that it is – you could be asleep at 5pm and wide awake at 3am. The therapy for this, though, is the same as for DSPS.
These two disorders have been studied extensively, and melatonin is a very normal part of their therapy, combined with strong light (sunlight) in the morning. There are two more therapies that are a bit more disputable:
- A very common use for melatonin is combating jet lag, where it’s taken to raise blood melatonin levels before your body would naturally produce them. With flying, you can travel quickly over a few time zones, and it would normally take about one day per zone to naturally adjust to the new light-dark cues. Melatonin taken just before bed can “jump start” those cues and make adjusting to the new time easier. Or so the theory goes…for every scientific melatonin-for-jet lag study that says it’s effective, there’s another one that says it isn’t. I would say that the only way to tell if it will work for you is to give it a try. Several of my jet-setting friends swear by it.
- The final melatonin treatment would be supplementation for night-shift workers. It can be used as a supplement before going to bed because the day-night cues aren’t there, so the blood melatonin levels aren’t either. But mostly it’s been touted for another reason – night-shift workers tend to work with artificial lighting, and have very low melatonin levels around the clock (again, because they’re light-dark cues aren’t there). Melatonin is a powerful antioxidant, and because of the normally low blood levels of it, cancer tumours occur more frequently in night-shift workers. So the supplementation might not only help you sleep, it may provide a cancer-fighting benefit as well. Again, this one is controversial, but intuitively it sounds reasonable. As with jet lag, I think it’s prudent to give it a try.
When researchers examine the actual blood plasma levels of melatonin in humans, they discovered levels that are quite low compared to the supplements that we take.
It normally would take supplementation of 0.3mg to 0.5mg to effect our blood levels at night in a significant, measurable way. Unfortunately, the supplements we buy often contain ten times as much as we need – 3mg, 5mg, and often much more. It’s been shown that too much melatonin can actually be worse for your condition.
If you are supplementing with melatonin for insomnia, make sure of the dose you are taking.
If possible, cut it down to as close to 0.3mg to 0.5mg as you can (I have 5mg pills, so the most I can realistically cut it down to is 2.5mg, which is still too much!).
Melatonin is available in North America as a pill, a capsule, in liquid form, a trans-dermal patch or it can be taken sublingually.
One more thing, make sure that your melatonin is synthetic not natural. Natural melatonin comes from the brains of other mammals, and could contain a nasty virus that you don’t want.
Calcium and Magnesium are two important minerals that affect sleep in profound ways. We all know the importance of calcium in maintaining strong teeth and bones, but most of us are unaware of it’s affect on sleep. And did you know that, in addition to being important for body function (including sleep) in it’s own rite, Magnesium is essential for the absorption of Calcium?
Calcium levels in our body are measurably higher during REM sleep, and when investigative cases of low or disturbed REM, researchers found calcium levels were lacking as well. When normal levels of calcium were reached again, normal REM sleep occurred.
One of the leading symptoms of magnesium deficiency is chronic insomnia, usually characterized by frequent awakenings. When patient magnesium levels are restored, their sleep is deeper with fewer interruptions.
Here is a partial list of where you might find calcium in your diet:
- milk or fortified soy drinks
- yogurt
- cheese
- tofu
- white/navy beans
- almonds
- sardines
- salmon
- oats
- turnip greens
- bok choy
- Oranges
Some foods that you would find rich in Magnesium include:
- wheat bran
- almonds
- spinach
- cashews
- soybeans
- wheat germ
- nuts
- oatmeal
- peanuts
- potatoes
- Rice
Although I used to supplement with Calcium and Magnesium, I now recommend getting enough of both minerals exclusively through your diet. Recent studies have shown that Calcium supplementation leads to a higher risk of heart attack! Also note that you need magnesium to metabolize calcium (about a 1:2 ratio).
Recommended Dietary Allowances for Calcium:
- 7–12 months - 260mg
- 1–3 years - 700mg
- 4–8 years - 1,000mg
- 9–18 years - 1,300mg
- 19–50 years - 1,000mg
- 51–70 years - 1,000mg (M) or 1,200mg (F)
- 71+ years - 1,200mg
Recommended Dietary Allowances for Magnesium:
- 1–3 years - 80mg
- 4–8 years - 130mg
- 9–13 years - 240mg
- 14–18 years - 360-410mg
- 19–30 years - 310-400mg
- 31+ years - 320-420mg
With the magnesium doses that have a range (>14 yrs), go to the NIH site for specific M-F-Pregnant-Lactating recommendations.
5-HTP (5-Hydroxytryptophan) is a naturally occurring, chemical precursor to both seratonin and melatonin -one that we've synthesized and now sell as a supplement.
Seratonin and melatonin are both important in the regulation of our sleep, and are seen in synergistic levels during the day - seratonin is pronounced in daylight, and shut down when it's dark - exactly the opposite of melatonin. Interestingly, seratonin drives the pineal gland where melatonin is produced...
In addition to sleep, 5-HTP is used for depression, anxiety, headaches, fibromyalgia, binge eating, ADHD, and others.
5-HTP acts primarily by increasing seratonin levels in the central nervous system. Since increased seratonin is known to be coincident with sleep, it makes sense for researchers to try and elevate these levels artificially.
5-HTP has been shown specifically to increase the amount of REM sleep you can get - although dosage levels seem to be important. Too much 5-HTP can cause vivid dreaming and nightmares, and too little and there's no effect. About 200mg of 5-HTP before going to bed seems to be the recommended starting dosage.
5-HTP hasn't been thoroughly clinically studied, so extra caution with it's use is warranted. Some of the reported side effects include:
Of particular concern is the interaction between 5-HTP and other medications in general. If you have any doubt, ask your pharmacist or doctor.
You’ll often find 5-HTP as either a stand-alone insomnia treatment or mixed with other “sleep-promoting” products like melatonin and l-theanine.
Theanine is a common amino acid found in green tea, and the particular derivation of it used in sleep supplementation is l-theanine (chemists will understand what the "l" stands for). It was first extracted and isolated from green tea leaves in the 1950’s, and is generally regarded as safe and approved for general population consumption (it’s basically tea!).
Theanine is able to cross the blood-brain barrier, and acts similarly to coffee in many respects. It has been shown to reduce mental and physical stress, as well as to increase focus and cognition.
L-Theanine is one of the premiere active components in green tea (this is partly why green tea is so good for you), and when extracted from tea leaves is now a popular, safe supplement found in aids to both focus and concentration, as well as a relaxant and a mild tranquilizer (ie: a natural antidepressant).
It's these relaxation and tranquilizer characteristics that have made L-Theanine a popular addition to many "natural" sleep aids. The one that I use occasionally has a mixture of melatonin (1.5mg), 5-HTP (15mg), and L-Theanine (100mg).
It's basically harmless, and it could have an impact on your relaxation for sleep, or your concentration for study! A little experimentation is in order to see if this supplement works for you…
CHAPTER SEVEN
Pharmaceuticals
This section talks about the drugs that man has invented - these generally don’t occur in nature, and we create them in a lab or a factory.
Sadly, I have personal experience with this class of chemicals. After a major medical trauma (a stroke), I found that I was unable to sleep. My doctor thought that sleeping was more important to my recovery than any side effect from a drug, so I started on a course of Lorazepam (one of the benzodiazapines - up next). This was, of course, before I knew anything about sleep and how to treat insomnia. It’s sufficient to say “I wish I knew then what I know now”.
If you ever look for sleep aids at the pharmacy or the grocery store, you’ll find that there’s lots of product to choose from. I’d like to break them down into two general categories:
- “Natural” supplements
- First Generation Antihistamines
The natural supplements normally contain a concoction of melatonin mixed with any number of other substances. These could include theanine, 5-HTP, chamomile, tart cherry, chamomile, goji berry, kava, valerian - basically anything that’s been associated with sleep.
My highly cynical advice for this stuff is “try it”. Your mileage will vary. It will work for some of you, and for others it will be a non-starter. Give it a week or two to see if there is a marked change (keep that journal). But your ultimate goal should always be to eventually wean off everthing.
The first generation antihistamines were made to fight allergies, but they also have a sedative side effect which is leveraged by OTC (Over-The-Counter) sleep remedies in some countries. This is a mixed bag, in some countries they’re OTC, and in others they’re still by prescription only.
They all use some derivative of promethazine, hydroxyzine, alimemazine or diphenhydramine - first generation antihistamines with the sedative side effect. Newer (second generation) non-drowsy formulations primarily use cetirizine or loratadine. Some of the common names you’ll hear in North America are Benadryl, Nytol, Unisom, Advil PM, Tylenol PM, Sominex and many others. Often, these “sleep aids” are sold with other active ingredients - the most common would be an analgesic for pain management (Tylenol PM, Excedrin PM, Nyquil).
While the long term use of the “Natural Supplements” haven’t been tested - they’re probably pretty safe. The antihistamines, though, are a different story.
Their efficacy will wear off over time - so you’ll need more and more to get the same effect. My experience is that they cause a next-day drowsiness as well - sometimes the next day hangover is worse than the insomnia.
If you take an OTC antihistamine, make it as short term and infrequent as possible.
We’ve briefly covered the OTC drugs - and now we’re into the heavy duty, must-have-a-prescription stuff. Remember that we’re listing these “remedies” in order of their side effects. As we progress, the side effects get more serious.
Although I cannot cover every possible sleep remedy your doctor might prescribe for you, this one is pretty popular where I live, so I thought it important to briefly cover Trazodone.
Like so many of the sleep meds, Trazadone (also sold as Desyrel, Oleptro, Beneficat, Deprax, Desirel, Molipaxin, Thombran, Trazorel, Trialodine, Trittico, and Mesyre) was invented as an antidepressant.
In the mid 1960's, an Italian research lab invented this new "SARI-class" of drug, and in addition to it's efficacy with depression, it was discovered early on that it was a significantly improved insomnia treatment on depressed patients who took SSRI medication. It also had a side-effect profile that was much lower than other insomnia treatments - the small list includes hypotension (low blood pressure), constipation and priapism.
In several countries, Trazodone is "officially" a prescription insomnia treatment - 100mg seems to be the standard dose. In several more, Trazodone is an "off-label" treatment - meaning that it's not "officially sanctioned” for it's use with insomnia - but it's used that way anyways.
In hospitals in Canada (where I live), Trazodone is often given as a first line insomnia drug, because it's been deemed "less addictive" or "non-addictive" and normally quite effective. For me, it did nothing, although I have friends that use this regularly and swear by it. After long term use they have discovered that it requires a short wean to get off the drug (unlike benzodiazapines which can have a very long weaning period).
As with most drugs, there are several interactions to look out for. Mixing trazodone with alcohol is dangerous, as is doing anything that requires concentration (like driving). If you're going to take the drug, make sure that you understand all the expected and unexpected side effects before you commit.
I’m using trazodone as an example of many, many off-label and on-label uses of antidepressants as sleep meds. It seems that every doctor has their favorite chemical - and I just picked this one as an example.
A side effect of many anti-depressants in small doses is sedation/sleepiness, and they’re seen as less dangerous that barbiturates or benzodiazapines. So that’s why they’re prescribed….
Same advice though - if you’re on them, get off them. Nothing good comes from being dependent on a chemical to get sleep.
Benzodiazapines are so popular (especially in North America) that they even have a nickname: Benzos.
Although in the USA they have primarily been usurped by more modern drugs like Ambien (inventively called a non-benzodiazapine) for sleep, they are still a staple in many parts of the world. Often, they are prescribed almost carelessly, without regard to their long term effects.
In addition to it’s status as a prescription drug, there is also a black market for their use recreationally.
When Benzos were first introduced onto the market in the 1960′s they were seen as a huge breakthrough – found to be much less dangerous than their predecessor – barbiturates (downers). All the benzos in the list are from the same family, and they all act basically the same way. The major difference (and I assume how a doctor chooses to prescribe one versus another) is their active concentrations, their different half lives, and the dominant receptor they affect. The specific half life of a particular benzo are available here.
Benzos primarily affect something called the GAMAa neurotransmitter in your brain. This neurotransmitter has several receptors, each with a different response. The receptors that benzos affect are:
- Sedation
- Hypnotic (sleep induction)
- Anti anxiety
- Anti convulsant
- Muscle relaxation
Benzos are used for a number of things, but I’m only interested in their use for sleep. So the first thing your doctor will do is pick a benzo that primarily acts on the hypnotic GAMAa receptor. The next step they’ll take is to look at the particular “half life” of the drug – the shorter half-lives are for insomnia, and the longer ones are generally for:
- Seizures
- Anxiety (often given to patients before surgery or an MRI)
- Panic attacks or panic disorder
- Alcohol withdrawal
Benzodiazapines prescribed for sleep are generally considered safe in the short term. This means a few days in a row, or an occasional pill every few months. Anything more frequent than that, and you’re asking for trouble (and it’s guaranteed to find you).
If you’re prescribed Benzos for anything other than sleep (or even if it is for sleep), I’d suggest you research this topic more completely, and ask your doctor lots of questions. Knowledge is power. This UK website would be a great start (note that the UK is on the forefront of trying to severely limit the use of benzodiazapines).
I was cautioned about this before starting with lorazepam, but (having never taken them before and having done no research) I agreed with my doctor and decided that my sleep was far more important than some drug dependency in the future.
If you take them:
- Periodically – every few weeks for a night or two – they work well.
- Short term – a couple of weeks – they work. They work well.
- Long term – over two weeks – they have a paradoxical effect. It not only takes more and more of the drug to get the same benefit, but when you find it’s time to quit – you can’t.
There are many warnings about trying to quit Benzodiazapines cold-turkey once you’ve got that physical dependency (after a few weeks of continuous use). It can cause seizures that could lead to death, schizophrenia, or suicide. Nasty, nasty stuff.
You’ll have to wean off the drug very slowly – normally taking several months. This has become such an issue that there is even a support group for it (again, based in the UK).
As if that weren’t enough (the long weaning period), it can cause an effect called “rebound insomnia”. This is where the lack of the drug (ie: weaning too rapidly) actually causes an insomnia worse than the initial reason you started taking it.
But if you persevere, you will get through it. Having a doctor that’s willing to “play ball” with you helps immensely. I’d say if you don’t have one willing to help, find another. You shouldn’t have to do this on your own. There are doctors out there that understand benzodiazapine dependence.
As I said earlier, it took me over a year to wean off lorazipam, and now when I occasionally take it (one night every couple of months), I find it does nothing… or does it?
Benzodiazapines may work well to help you sleep – but the sleep that you get might not be that refreshing. And you’d never really know unless you had a tool to help you look (I happen to have a Zeo Sleep Monitor).
Benzos are known to suppress deep sleep. One night I thought I’d take 1mg of lorazepam (Ativan) to see what it does, and if I could measure it. I could.
Notice the very short deep sleep – about half of what I’d normally get. It also occurs later in the night than I would normally experience.
Benzos are known for suppressing deep sleep.
Another newer finding on the horizon is that bezos don’t really help you sleep at all - they just help you forget the fact that you were awake. Take a look at my blog to see what’s new in this area (at the time of this edition, this is really new information).
The bottom line for me is that these drugs may not even work, and if they do work, the results they give you aren’t what I bargained for. So I will discontinue even infrequent benzodiazapine use.
*It’s important to wean off benzodiazapines slowly, so go to a specific benzodiazapine withdrawal resource to find out specifically how to do it. They’ll generally take the dose you’re on now, start to reduce it very slowly in very small steps, and eventually wean you off the drug completely. This is not something you want to do on your own. You should tell your doctor (who wrote the initial prescription for you I assume) what you’re doing, and hope that he/she plays ball with you. In many cases, the benzo rehab experts will want you to switch drugs completely - it makes the taper easier to do.
Here’s a complete list of all the benzodiazapines currently available (listed alphabetically), along with their associated brand/trade names:
- Alprazolam = Helex, Xanax, Xanor, Onax, Alprox, Restyl, Tafil, Paxal
- Bretazenil = N/A
- Bromazepam = Lectopam, Lexotanil, Lexotan, Bromam
- Brotizolam = Lendormin, Dormex, Sintonal, Noctilan
- Chlordiazepoxide = Librium, Risolid, Elenium
- Cinolazepam = Gerodorm
- Clonazepam = Rivotril, Klonopin, Iktorivil, Paxam
- Clorazepate = Tranxene, Tranxilium
- Clotiazepam = Veratran, Clozan, Rize
- Cloxazolam = Sepazon, Olcadil
- Delorazepam = Dadumir
- Diazepam = Antenex, Apaurin, Apzepam, Apozepam, Hexalid, Pax, Stesolid, Stedon, Valium, Vival, Valaxona
- Estazolam = ProSom
- Etizolam = Etilaam, Pasaden, Depas
- Flunitrazepam = Rohypnol, Fluscand, Flunipam, Ronal, Rohydorm,
- Flurazepam = Dalmadorm, Dalmane
- Flutoprazepam = Restas
- Halazepam = Paxipam
- Ketazolam = Anxon
- Loprazolam = Dormonoct
- Lorazepam = Ativan, Temesta, Tavor, Lorabenz (this is the stuff I was on)
- Lormetazepam = Loramet, Noctamid, Pronoctan
- Medazepam = Nobrium
- Midazolam = Doricum, Versed, Hypnovel, Dormonid
- Nimetazepam = Erimin
- Nitrazepam = Mogadon, Alodorm, Pacisyn, Dumolid, Nitrazadon
- Nordazepam = Madar, Stilny
- Oxazepam = Seresta, Serax, Serenid, Serepax, Sobril, Oxabenz, Oxapax
- Phenazepam = Phenazepam
- Pinazepam = Domar
- Prazepam = Lysanxia, Centrax
- Premazepam = N/A
- Quazepam = Doral
- Temazepam = Restoril, Normison, Euhypnos, Temaze, Tenox
- Tetrazepam = Mylostan
- Triazolam = Halcion, Rilamir
In addition the benzodiazapines, there’s another major class of insomnia pharmaceutical out there that works in a very similar way, and has a similar side-effect profile, but is chemically quite different from the benzos - and we creatively call them non-benzodiazapines or The “Z” drugs.
Their called the “Z” Drugs because of their names: Zolpidem, Zalepon, Zopiclone and Eszopiclone - there are a couple of others but these are the most popular.
You may not recognize these drug names, but I’m sure you recognize their trade names:
- Zolpidem - Ambien, Stilnox
- Zalepon - Sonata
- Zopiclone - Imovane
- Eszopiclone - Lunesta
Again - these are only a few of the popular drugs out there - if you can’t tell from your prescription which one it is, ask your pharmacist.
They work exactly the same as benzodiazapines except that they all tend to target the hypnotic (sleep induction) GAMAa receptor. So they are more targeted that a plain-old benzo.
They work quickly (less than a half hour) and have a short half-life (two to three hours) - so this is one of the other primary differences from the benzos. The other is that they are assumed to be somewhat safer and easier to discontinue use than their benzo cousins.
As mentioned above, the list of side effects for the “Z” drugs are similar to benzodiazapines:
- Amnesia, hallucinations and delusions
- Mood swings
- Nausea and vomiting
- Impulsivity
- Altered thinking
- Changes in libido
- Poor motor coordination - including speaking
- Increased appetite
- Impaired judgement and reasoning
- Headaches
- Memory Loss
- Thoughts of Suicide
And the biggest worry if you don’t experience any side effects:
- Rebound insomnia when stopped
There are also frequent reports of unusual sleepwalking behaviour when under the influence of Zolpidem (Ambien - the most popular of the “Z” Drugs) - acting as though you are completely awake, and making it extremely difficult for anyone to tell that you are actually asleep. Suicide and Ambien use is in the news now as well.
Short term use (under a few weeks) of Zolpidem has been deemed safe for initiating sleep. It’s effects wear off so quick that it’s not used to maintain sleep (so it’s no good for frequent awakenings). Longer term use is likely to cause a physical dependency, where the withdrawal symptoms and timeframes can be just as bad as the benzos they’re supposed to replace.
In my opinion - use them if you must, but use them for the shortest amount of time, at the lowest possible dose. It’s the same advice I’d now give for the benzos. Fine for a week or two, but any more than that and you’re playing with fire.
Eszopiclone (Lunesta) is more-or-less the same drug as Zolpidem (Ambien), with only minor variations with the drug molecule itself. Actually, in Europe it was denied a patent because it was deemed to be too similar to existing drugs.
Along with Zolpidem (Ambien) and Zaleplon (Sonata), they are the three most prescribed sleeping pills in the USA.
A recent arrival on the insomnia treatment scene is Intermezzo. It’s basically a smaller dose of Zolpidem/Ambien (1.75-3mg versus 10mg for typical doses) administered sublingually (under the tongue) for faster absorption into the bloodstream. Not terribly innovative, especially since Zolpidem is available as a generic drug at a fraction of the price. If you want a smaller dose of the Ambien/Lunesta pill, cut it in half!
Once you start looking for pharmaceuticals for sleep, you find them everywhere. And you keep on finding them. At some point, you have to stop and admit that the field is evolving too fast to keep up.
So this is what you should do if anyone (your doctor, your friend, your clinician, your hairdresser) tells you about some miracle sleeping pill. Go online to Wikipedia (it’s the only mediated general information source out there), or some trusted medical news source (like the Harvard School of Medicine) and look it up. Find out what it’s really all about. Pay special attention to the side effects and physical dependency. Then quiz your pharmacist and doctor about it. Be an informed patient.
That same thinking holds true for everything I’ve listed here as well - we learn new stuff about old stuff all the time.
CHAPTER EIGHT
Other Stuff To Try
There are all kinds of “therapies” and “supplements” that claim to help you with sleep.
I generally categorize them in one of two ways:
- They’re something you consume (drink, eat, or absorb) that relaxes you - making sleep come easier.
- They’re an activity that you do, and that activity calms and relaxes so sleep comes easier.
As you can see, all of the holistic or natural sleep treatments - lavendar, kava, CBT, chamomile - work at one of these two levels. So do the rest of the “alternative treatments”. I won’t expand on them here, but if you were to do a little investigating you’ll find proponents for any of them:
- Feng Shui
- Ayurvedic Treatments
- Accupunture
- Traditional Chinese Medicine
- Goji Berry
- Tart Cherry
- Howling At The Moon
I put the last one in this list to say that almost anything has been reported to enhance sleep. If you believe that it can, it might! Sleep is all in your head.
The target, it seems to me, should always be to use the most minimally invasive treatment for insomnia that you can. And that is CBT. Always aim to resolve your insomnia with CBT.
CHAPTER NINE
Parasomnias
CHAPTER TEN
Sleep Apnea
Sleep Apnea is a serious sleep disorder, and often the people who suffer from it don’t even realize they have it.
Sleep Apnea is the technical name for a condition where you momentarily pause breathing, or have very shallow breathing, for a short time while you are asleep. This pause can be as short as a few seconds or as long as a few minutes, and it happens five to thirty times an hour (for really serious cases, it can be more!).
The actual pause in breathing is called an apnea, and it is defined into three separate categories:
- Central Sleep Apnea (CSA) is a very minor (<1 actual="" affected="" airway="" an="" and="" apneas.="" are="" as="" asleep="" brain="" breathe="" by="" cause="" caused="" condition.="" csa="" deep="" dive="" doctor="" effort="" for="" from="" get="" help="" if="" in="" internal="" into="" is="" isn="" it="" just="" lack="" mentally.="" obstruction="" of="" often="" osa.="" outgrow="" people="" physiological="" representative="" respiration="" s="" say="" sleep="" some="" span="" suffice="" suspect="" t="" tells="" that="" the="" therapies="" there="" to="" trigger="" try="" when="" while="" will="" you="" your="">current CSA research. If you suspect CSA, you’re way beyond the scope of this book!
- Obstructive Sleep Apnea (OSA) is the most common type of sleep apnea (about 85%). With OSA, there is something physical that impedes the flow of air into your lungs. So here we have the brain working fine, telling your lungs to push air in and out, but an obstruction gets in the way. Snoring with OSA is very common, and is likely the only symptom you’ll know about (or rather, your partner will know about).
- Mixed or Complex Sleep Apnea. This one is actually a mixture of the first two (CSA and OSA) and it’s thought that somehow the continued presence of OSA might bring on the CSA. Nobody is really sure how this works.
The diagnosis of any of these types of sleep apnea depends on an actual awareness that you have it! Most often, this comes about by your spouse or partner talking about your gaps in breathing at night, or perhaps your excessive snoring (although it’s not really the snoring that’s the problem – it’s when you stop snoring for short durations during the night).
If the sleep apnea is serious enough that you’re missing out large chunks of restful sleep, then part of the diagnosis can be your sleepiness and fatigue the following day (every day), vision problems, and slower than normal reaction times.
Unfortunately, some people with the problem become so conditioned to feeling tired that they come to think that it’s “just normal”, and they never get the sleep apnea diagnosed – this can go on for years or decades!
You’ve decided to go visit your doctor because you suspect sleep apnea - likely because somebody has told you about your excessive snoring, or they notice gaps in your breathing at night. What the doctor should to is take a couple of steps to confirm that you have an issue:
- Confirm all the daytime fatigue symptoms you’ve already recognized – tired, unfocused, uncoordinated, general laziness. If they’re satisfied that there might be an issue;
- Order a sleep test – either a sleep lab polysomnigraph test or something similar you can do at home (normally less accurate, but more convenient – and any obvious apneas will show up in both - when I suspected a case of CSA, I had a blood oxcymeter test overnight to see if my blood oxygenation dipped during sleep.).
Now you’d think the results of this test would be cut-and-dry, and if you have a serious case they probably are, but there’s some controversy here. There are so many variables involved – age, sex, fitness, diet, smoking, alcohol use, number and severity of apnea episodes at night, and on-and-on, that what one doctor says is apnea may not be confirmed by a different doctor. In my opinion this comes down to an interpretation of the “technical definition” of sleep apnea – but if it’s affecting your life – who cares if it’s officially an apnea?
If your tests spot multiple “apnea events” at night, and you’re drowsy the next day – then you have sleep apnea and you should take steps to improve your rest.
Obstructive sleep apnea is a serious issue, but for a large percentage of people some simple lifestyle interventions could be enough to reduce or eliminate the condition. I would suggest trying these first before jumping to more extreme measures:
- Lose some weight. People with a BMI of >30 are at a higher risk of OSA. Sometimes losing just a bit of weight is enough to reduce the obstruction so it’s not impeding your breathing. Calculate your BMI here.
- Don’t use muscle relaxants – check your medications because they may contain a muscle relaxant and you don’t even know it! This could cause the obstruction to “relax” and fall back into your airway. If you take a sleeping pill – make sure it doesn’t relax muscles as well. Check pain meds too.
- No alcohol – it relaxes your muscles. So if you drink, make sure it’s out of your system before you lie down to sleep (several hours).
- Sleep partially sitting up. Researchers find that a sleeping angle of about 30 degrees can prevent an obstruction from blocking airways. You can prop up the head of your bed with blocks or books.
- Sleep on your side versus your back. Sewing a tennis ball into your night shirt or pyjama's is a common way of dealing with this, as it prevents you from rolling on your back.
- Quit Smoking. This has so many health ramifications, don’t be surprised that it’s here too. Smoking affects respiration.
- This last one, as strange as it sounds, has been proven to work for many. Practise the didgerido! It’s thought that it strengthens the mouth and throat muscles so much that many OSA’s don’t present themselves at night. Any exercises that strengthen the mouth, tongue, or throat can help with OSA.
If these strategies don’t work, or if your sleep apnea is pretty serious, consider some of the longer term strategies discussed next – surgery, implants or appliances. They may involve more discomfort (and expense) up front, but the long term results from them is very good.
These methods work best with the more serious cases – if you have a major obstruction or cannot get enough respiratory pressure, this is likely the route you’ll head when the natural therapies aren’t enough:
- A common method for handling sleep apnea, at least in the short term (because they’ve found that long term, people tend to stop using them) is the CPAP (Continuous Positive Airway Pressure) machine. It’s strapped on to your nose and mouth (much like an oxygen mask in a hospital) and provides pressurized air to you all night long. The pressure is adjusted so it provides just enough to overcome whatever your obstruction is.
- Another method would be some kind of surgery or implants to either clear away the blockage or enlarge the airway. These solutions tend to be much more long term that a CPAP machine, but they do involve surgical risks of their own.
- An oral appliance – probably prescribed for you from a dentist that specializes in sleep disorders – can prove effective. The appliance moves your jaw forward and opens your airway at night.
CHAPTER ELEVEN
Parasomnias
A parasomnia is simply abnormal or unnatural behaviour during some phase of sleep. It could be an emotional response, a behaviour, a perception or a dream.
Most parasomnias occur during a sleep transition - from either wake to REM sleep, or wake to Non-REM sleep.
While there are several different parasomnias, we’ll talk about the most common here:
- Nightmares (not really classified as a parasomnia, but I didn’t know where else to put it).
- Night-Terrors
- Sleep Walking
- Bruxism (Teeth Grinding)
- Restless Leg Syndrome
Nightmares are generally considered to be any dream you have that provokes a strong negative emotion - normally fear or horror. They are relatively uncommon in very young children, increase in frequency as you get older, are most common with teenagers, and then become much less frequent again as an adult.
Most people wake up after a nightmare and have a hard time falling back to sleep - their negative emotions are still running pretty high.
There are some potential triggers to nightmares that you should be aware of, and try to avoid if you can:
- Eating late at night can increase your metabolism and gives the brain extra things to do.
- Extra or unusual stress or anxiety that causes the brain to work overtime.
- A fever can stimulate nightmares.
If nightmares are recurrent, they can substantially affect your sleep and lead to overall insomnia. This is where they turn from being a minor irritant into a major one - playing havoc with your daytime life.
If you suffer from recurrent nightmares (often having the same theme) the recommended strategy is cognitive therapy (not to be confused with cognitive behavior therapy). The majority of recurring nightmares are the result of some unresolved traumatic event in your life. Talking through that event with a professional therapist is the best way to work to resolution. Post Traumatic Stress Disorder (PTSD) is a prime example of the potential roots of recurring nightmares.
For most of us, with no outstanding issues to resolve, understand that nightmares are common and are just a part of growing up. It’s uncommon, but not unusual, to experience the odd nightmare as an adult (my wife still does, but I haven’t had one for decades).
If your nightmares are infrequent, they shouldn’t cause you any concern - they’re completely normal.
People often mix up the terms “nightmare” and “night-terror”. They are not the same thing.
Night-terrors are dreams that cause real feelings of dread or terror - generally much more vivid than a nightmare. They mostly occur in the time when you are just exiting N3 - deep sleep. They’re also reported to occur during daytime naps.
They occur less frequently than nightmares and only a very small percentage of us (1-6%) will ever experience one during our lifetimes.
Instead of just waking up and being unable to get back to sleep (like a nightmare), night-terror sufferers will “bolt upright” in their bed, often screaming with panic and fear on their face. They will exhibit physical symptoms of the night-terror as well - increased respiration, sweating, and rapid heart rates. It’s as though the “event” was so real that they’ve actually experienced it … and I guess in their minds, they did.
Sometimes, because you’re really still in N3 sleep and your limbs aren’t paralyzed, night-terror sufferers will lash out with their arms and legs. This makes things even more precarious and could lead to injury of anyone nearby - including the sufferer. It’s like terror-driven sleep walking. You may think they are awake - because they behave like they are - but they are really still deep asleep (some small children may indeed be awake, but they are so disoriented it’s hard to tell).
Treatment for night-terrors generally take one of three paths:
- Overtiredness is a common cause, and the solution is simply to modify sleeping schedules to get the rest you need.
- Cognitive therapy, just like with nightmares, can help - talking through the terror.
- In some cases, benzodiazapines could be prescribed to help with sleep (my own experience shows that it limits N3 sleep).
I’ve never known anyone who suffers from night-terrors, but it sounds awful. The odd nightmare as a kid was real enough for me, thank-you very much.
Sleep walking is another parasomnia that is common, especially among children - as high as 20% of children will experience it, and the frequency tends to diminish as we get older.
Strangely, there is a hereditary factor associated with sleepwalking - if one parent sleepwalked, chances go up to 45% that you will too. If both parents sleepwalked, your odds go up to 60%.
Although the subject appears to be awake, they will be asleep, but capable of some interestingly complex tasks - sleepwalkers have been known to send emails, set dinner dates, cook, drive, have sex - incredible stuff for somebody who’s asleep!
As with the other parasomnias, sleepwalking generally occurs early in the night during a transition from N3 deep sleep.
Sleepwalking events generally last from 30 seconds to 30 minutes, and because of the potential for harm to both the subject and other people (imagine cooking, driving, or walking down the street), it’s to be taken seriously.
The current thinking behind sleepwalking is that the brain hasn’t sufficiently matured to “stay” or “leave cleanly” N3 stage sleep (when researchers studied teenage sleepwalkers they see unusual high-voltage delta wave activity). Other causes could be sleep deprivation, excessive tiredness, or fever.
Treatment for sleepwalking can be broken down into:
- Growing up - people tend to outgrow it.
- Sleepwalk-proof your house in the interim (lock doors, windows, cabinets).
- Low dose benzodiazapines (with all my warnings).
- Good sleep hygiene can prevent the onset of it in the first place.
Sleepwalking is really common, and you’ll probably know someone today who suffered from it. Chances are they outgrew it too.
Bruxism is the grinding of teeth and/or the clenching of the jaw during sleep. It’s one of the most common of the sleep disorders, and most of us do it (did it) as some point in our lives.
Mild cases are inconsequential, but health issues arise when the clenching/grinding get more severe. Some of the consequences of bruxism can include:
- Jaw pain
- Unnatural wearing of tooth surfaces
- Fracturing of the teeth
- Gum recession
- Neck Pain
- Earache
- Insomnia
Bruxism is now thought to be a “learned behavior” which then becomes a habit. Once the original stimulus that started the bruxism goes away, the “habit” can remain, so any cure for this condition has to deal with the habit.
The first person that’s likely to notice the grinding, if it hasn’t already presented itself with pain somewhere, is your dentist. They’ll see unnatural wear of your teeth. The next step for them will be some kind of oral appliance to limit the damage to your teeth (like a mouth guard). Like all the sleep-meds, this is only a band-aid to the condition. You really need some kind of therapy to get at the actual habit behind the grinding and clenching.
As with everything else, it’s back to CBT, although this time it’s tougher because you’re actually asleep when experience the bruxism. Biofeedback seems to be the treatment of the day, and it helps to “unlearn” the grinding/clenching habit.
When your doctor or dentist recommends an appliance for this condition, ask about CBT too - the appliance will limit the damage, but the therapy will cure the problem.
RLS (Restless legs syndrome) is also called Willis-Ekbom disease. Sir Thomas Willis acknowledged the problem in 1672, when he said:
“Wherefore to some, when being abed they betake themselves to sleep, presently in the arms and legs, leapings and contractions on the tendons, and so great a restlessness and tossings of other members ensue, that the diseased are no more able to sleep, than if they were in a place of the greatest torture.”
Like his quote says, it’s a neurological disorder that causes an irresistible urge to move your body (normally your leg, but it can also be a phantom limb, an arm, or your torso) to try and stop unpleasant or “weird” sensations. When you move the affected body part you get normally get temporary relief of the RLS.
Most people describe RLS sensations as “itching” or “tickling” - but short of moving, the sensation won’t stop. These symptoms normally begin just as you’re falling asleep, or when you are awake but very relaxed (like when reading). Seems to describe N1 or N2 sleep, doesn’t it?
RLS sufferers tend to exhibit “jerky” limb motion while they sleep, which leads to the major disruption of their night and causes them to wake up frequently. This is the hallmark symptom of RLS.
RLS, just like insomnia in general, is an entire spectrum of disease. Some people have it, but aren’t affected much at all. Others have it, and their quality of life is severely hampered. RLS is also controversial - many doctors don’t even recognize the condition - and if they do, they’ll all regard it somewhat differently. As for treating it - it’s a mixed bag.
There are drugs available that are said to treat RLS, but just like the “disease” they are quite controversial - and they’re mostly promoted by the pharmaceutical companies.
A common source of the RLS is often another underlying condition like iron deficiency or varicose veins. Once you treat the underlying condition, you resolve the RLS.
If you suspect (or know) you have RLS, study up on it. You’ll find that there’s a shopping cart of opinions about it as to it’s actual existence, source of the disease, and treatments.
CHAPTER TWELVE
Narcolepsy
Narcolepsy is a sleep disorder that’s characterized by both excessive sleepiness and “sleep attacks” that occur at inappropriate times - like when you’re at work or driving a car!
Narcoleptics generally have disturbed sleep during the night (as well as entering REM really early in the evening - often dreaming after 5 minutes), and have a weird sleep pattern during the day as well (it’s often confused with generic insomnia).
Cataplexy is another frequent problem a narcoleptic faces. It’s sudden muscular weakness - and is often brought on by strong emotions. It can be a hardly noticeable relaxing of the jaw all the way to the extreme dropping of the head, weakness of the knees, or a total collapse. Eyesight (hazy) and speech (slurred) are also often affected.
A narcoleptic doesn’t suffer from any mental illness or a psychological problem - this is a neurological issue (I can vouch for neurological problems when your brain doesn’t communicate properly with the rest of your body - my stroke had that affect on walking, speech, sleep, emotions, etc). Researchers believe it is an environmental issue (like a virus) when you’re very young and the brain is developing that triggers some genetic mutation.
Narcolepsy can be treated, but it can’t be cured. Because the disorder can change over time, and the response to medicines changes as well, close monitoring is essential. Most often, control of narcolepsy takes the form of some kind of stimulant to keep the nervous system “awake” - amphetamines are usually the way it’s handled.
I had a colleague years ago who suffered with narcolepsy, and his life was more-or-less normal (from the outside looking in), except that he popped low-dose amphetamines all day long.
CHAPTER THIRTEEN
Jet Lag
If you’ve ever traveled for more than an hour East-West (or West-East) on an airplane, then there’s a good chance you have experienced jet lag.
Jet lag is a new phenomenon for mankind, as it only happens when we travel at high speed, and our new location runs contrary to our internal circadian-driven clock - the timing of day and night is different than at home. It’s only in the last century that man could even experience jet lag, as all other manners of motion were relatively slow (ship, train, horse, car), and your internal clock had no problem keeping up.
The more time-zones you pass through, the more messed up your circadian rhythms become. It’s commonly believed that it takes about one day per timezone for your internal body clock to catch up (for example, flying from New York to LA – three timezones – would take you three days to re-establish a proper wake/sleep routine). There are some things, however,that you can do to aid in the severity of jet lag.
Jet lag may not be unavoidable, but you can likely make it far less miserable. Note that flying East to West (because you are extending your day rather than compressing it) is generally easier on your body than West to East air travel.
- Don’t allow your internal clock to reset by sleeping. If you have to nap make it no longer than 30 minutes. Let your internal clock reset with the new day/night cues at your destination.
- Avoid caffeine and liquor during your journey. A drink or two before or during your flight will make things much worse. Stay well hydrated during the flight – water is best. The inside of an airplane has very low humidity, and you likely can’t tell that you’re getting dehydrated.
- If you have to eat at all, eat lighter than you normally would. I’ve heard that avoiding food altogether makes the jet lag a non-event.
- Get outside as much as possible at the destination. This helps to reinforce the new daytime cues.
- Change your watch as soon as you step on the plane, and do everything (eat/sleep) on the new timezone.
- Wear an eye mask and ear plugs if you have to sleep on the airplane (based on the new clock). Block out as much noise and light as you can.
- If your trip is only for a day or so, and you can accommodate it, stay on your home timezone so you won’t have to experience jet lag twice (one at the destination, and again when you get home).
- When travelling East to West, try to fly as late in the day as you can. That way, when you arrive, it’ll already be late in the day in your destination (and you won’t have to fight off sleep as long).
- Exercise at your destination - even if it’s only a walk around the block, can re-energize you and help reset the internal clock.
- Several international travelling friends have mentioned that Day Two at the destination tends to be much worse than Day One. Because of this, many will avoid a busy schedule on Day Two.
- Many travellers swear that using melatonin speeds up or eliminates the whole jet lag phenomenon. See the Melatonin section.
- Although I don’t recommend them, short term use of sleeping pills like Ambien and Sonata can help you sleep when you absolutely can’t otherwise. Remember the dangers of using pills too often!
If you remember these twelve simple steps next time you take a long flight, there’s a very good chance that the resultant jet lag will be a minor annoyance instead of a major upheaval to your trip.
CHAPTER FOURTEEN
Circadian Rhythm Disorders
Most of these disorders were discussed in the Melatonin section, because that’s a common part of therapy for them. Regardless, here’s much of that same information again…
Circadian Rhythm Disorders (CRD’s) are primarily a disconnect with the clock on the wall and your internal “body clock”. Their timing is off - they are tired when the rest of us are awake, and awake when the rest of us are tired. If left on their own with no external “clock” to worry about, CRD sufferers would experience a full night’s sleep - but it could be from 4am to noon. Unfortunately, not many of us can ignore that external clock, and people with CRD’s can suffer terribly.
There are two different sources for circadian rhythm disorder: external and internal. Externally caused CRD’s include jet-lag and shift-work, while internally driven CRD’s are Delayed Phase Sleep Disorder (DSPS), Non-24-Hour Sleep-Wake Syndrome, Irregular Sleep Wake Rhythm and Advanced Sleep Phase Syndrome.
Unfortunately, because the obvious symptom is tiredness, many CRD’s are misdiagnosed as simple insomnia or, worse yet, the doctor doesn’t even know that these disorders exist.
- Jet Lag has been covered in this section already, so jump over there if you need a refresher.
- Shift Work Sleep Disorder affects people that work afternoons or nights, and are unable to get the proper “cues” from the environment. They have a hard time getting the rest they need because they’re tired when they’re working, and wide awake when they’re supposed to be asleep.
- Delayed Sleep Phase Syndrome, or DSPS - go back to Melatonin for more detail.
- Non-24-Hour-Sleep-Wake-Syndrome - again, back to Melatonin.
- Irregular sleep wake rhythm is where we see a person sleep at irregular times, usually more than twice a day. They wake up often during the night, and take naps during the day. When taken in total, though, their sleep time is normal.
- Advanced Sleep Phase Syndrome is being unusually tired earlier in the evening, and then wide awake very early in the morning.
Fortunately, the remedies for all of these CRD’s is the same. Leading the list is fundamental sleep hygiene. The second would be light therapy (bright artificial light or sunlight) first thing in the morning, normally combined with a melatonin supplement at night - this resets the whole melatonin/circadian cycle. If your clock is too far adrift, these therapies might be timed to change your internal clock an hour or two at a time.
This section could go on for a long time - there are hundreds of sleep maladies and I’ve only touched on some of the more common ones (although narcolepsy and Non-24-Hour-Sleep-Wake Syndrome aren’t very common).
If you have an issue that I haven’t discussed here - sorry. Leave a note on my blog and I’ll see about it in a future edition.
The next section will discuss the kinds of technology you can use to see just how well you do sleep at night. Remember, you’re very bad about judging your own sleep!
CHAPTER FIFTEEN
Technology
When evaluating technology for sleep management, I’d like to think of it as three different methods:
- Brain Entrainment - we’ve covered this one, but because you can load this stuff on your iPhone, I’m including this in the tech section.
- Accelerometer Based - these are all the devices that rely on body motion to determine sleep state.
- Brainwave Monitoring - these devices rely on EEG readings from your brain to determine sleep state.
There are several products available in each category, so I’ll only cover a couple of them. Once you read a device-specific datasheet, you’ll be able to tell which category they fall into - and once you know that, they all work fundamentally the same way from product to product.
Note that the products I talk about here are available at retail, and accessible by everyone.
The Brainwave Entrainment apps are pretty ubiquitous in the online app stores for Apple and Android devices. All you have to search for is “brainwave entrainment”, “isochronic tones”, or “binaural beats” or even “sleep” and you’ll get several hits.
They all have some kind of pleasant soundtrack with the entrainment embedded in the music/sounds. The tracks will be of varying lengths so make sure the one you get is long enough for your needs (some are five minutes, some run all night).
My recommendation would be to try some of the free versions of this software to see how you like it, and how well it works for you. Once you’ve determined that it will benefit you, invest a whopping $0.99 to download the full versions.
There’s lots of them out there - try “AmbiScience”, “Pzizz”, or “aSleep” to start. Don’t pay for anything until you’ve tried it out (most of them have a free version to try first).
This category gets bigger every month. It’s now so popular that there’s even a term for it: “The Quantified Self”.
Because so many of our devices (I’m thinking Smart-phones here) have built-in sensitive accelerometers, and we tend to move in “patterns” when we sleep, it made sense to measure that movement with the phone!
These apps work by placing your Smart-phone on the bed with you at night (beside the pillow). Once it’s calibrated properly (most do this on their own), it can measure your movement at night. This movement is translated into the sleep stage that you are experiencing - REM, Deep, Light, and Awake. Although nowhere near as accurate as an EEG device (like a Zeo or a sleep lab), it does a reasonable job of predicting sleep states.
The primary purpose of these apps is to use them as smart alarm clocks - to ensure that you are awoken during a lighter phase of sleep. We’ve all been woken from a Deep Sleep, and have suffered through the disorientation and grogginess that is inevitable. These apps try to avoid that.
In addition to the Smart-phone enabled devices, there are also body-based ones. They rely on an attached device with a built-in accelerometer that transmits movement information back to some central data-gathering point (another computer of some sort) - normally in a non-real time batch mode. They can do much more than monitor sleep - as it can integrate any movement you make (asleep or awake) into all kinds of measurements - calories burned, distance travelled, steps walked, etc.
Popular devices that fall into the Smartphone category would include Sleep Cycle and Sleep As Android , and the wearable devices would be like the Jawbone Up and FitBit Ultra … note that by the time you read this these devices and apps will probably be obsolete and replaced by something else - such is the way for high tech!
I’ve tried many of these devices, and they are very good for general monitoring of your movements through the day, but none are anywhere near as accurate as the EEG/Brainwave monitor device(s) for sleep - and that’s next…
This category includes my favourite sleep monitoring device - the Zeo Sleep Managment System (since gone off the market - I’m leaving the section in here so you can be aware when another similar product eventually makes its way to market).
It consists of a headband that you wear at night (the actual device that monitors your brainwaves) and a remote data logger - it can be a stand alone device (Zeo Bedside) or an application on your Smart-phone (Zeo Mobile). The version I use is Smart-phone based, and cost about $100 over the cost of the phone.
The data gathered overnight shows up in two places; on the Smart-phone itself, and a more granular version on a user-website (it uploads this automatically with the mobile version, and manually with the bedside). The user website is a service that all registered owners can subscribe to for free, and it gives you access to several data manipulation services for your sleep analysis.
Every morning, Zeo will give you a “score” of how you slept last night – they call this the ZQ. This ZQ number is very personal – everyone’s will be different – but it’s a good relative measure of how you slept. If you had a lousy night’s sleep one night, it should be reflected in your ZQ. If it was a great night, again it should be reflected in a higher ZQ (this example is one of my lousy nights).
In addition to this one ZQ number, the Smart-phone ap will show you basic information like the amount of Deep Sleep you got, REM you had, number and duration of Awakenings you experienced, Light Sleep you got, and the Total Sleep you received.
Data manipulation on the user website will give you several additional views of the information:
- Total Time Asleep
- Time in Deep Sleep
- Time in REM Sleep
- Time Awake
- Number of Awakenings
- History of your sleep over time – using whatever sleep variable you’d like (REM/Deep/etc)
- Detailed (every 5 minutes) graphical breakdown of your sleep every night.
- Trending graphs, where you can look at any one variable as it changes over time, as well as show how other variables affect that trend.
- Cause and effect graph – take any of the sleep factors (it has several defaults, and you can add your own) and chart them against eleven different sleep results
There’s a section of the Zeo website set aside for personalized coaching as well. You fill in some basic information about yourself, and it starts to track the sleep data that you’ve uploaded to the site. Over time, it takes this sleep data and recommends changes you can make to improve your sleep. Some of these changes are pretty basic, and some are more advanced, but I found the advice to be very comprehensive. The coaching section includes:
- Evaluation of your sleep fitness today
- Learning how to relax your way to sleep
- Making your bedroom conducive to sleep
- Optimizing your sleep schedule
- Powering down in the evening
- Eating and drinking smarter to improve your sleep
- Harmonizing your sleep with your housemates
It wraps it all up with how to create a routine out of all that you’ve learned – sort of an amalgam of the sleep practices you’ve figured out that work for you.
Overall, if you’re serious about figuring out your own sleep patterns - this is basically a “sleep lab in a box”. I highly recommend it.
I’ve tried all three types of these devices, and they’re all good at what they do.
It all depends on what your objective is:
- To get the biggest bang for your buck, it’s hard to beat an app for your Smart-phone. To get some brainwave entrainment and a smart alarm clock would cost you $2.00 or less. That’s hard to beat.
- To get more than just sleep information, but fitness information that paints a bigger picture of you, the wearable devices are fantastic. You won’t get the sleep data accuracy like a Zeo, but Zeo can’t tell you how far you’ve walked either. I use a FitBit every day to see how far I’ve walked…
- For the ultimate in detail about your sleep, you cannot beat the Zeo (or the future device that will replace it). You can even download all the data and manipulate it yourself if you’re truly anal.
In the end - get all three!
CHAPTER SIXTEEN
Conclusions
So here we are at the end of a short book about sleep. And if you’ve made it this far, I’d ask your indulgence for another few seconds.
Since I’ve tried many of these “remedies”, and have good knowledge of people who’ve tried the ones I haven’t, I have formed a pretty clear conclusion about sleep.
“It’s all in your head”
Once you buy into this argument, you’ll understand that anything you take is just a band-aid on a wound - it doesn’t help heal the wound. All that the supplements do (prescription, OTC, natural herbs, anything) is postpone finding what really works.
Devices like FitBit or Zeo are simply analytical tools to help you discover what’s really going on. Again, no cure here.
What really works for me (and it’s still a struggle, but sleep is slowly getting better) is avoiding all the supplements, measuring and keeping track of all the variables (sleep, exercise, food), and working on retraining my brain.
This is as simple as sticking to a routine, learning to relax, not being stressed out about sleep, and knowing that this is the path that will get me back to health.
So use the supplements in the short term to help you through those troublesome nights, but know that the solution is really “all in your head”.
So if I had to summarize this entire book in a few words, they would be: “leave the drugs, and learn to relax”.
Have a good night!
I run a small sleep blog as well, and it might be somewhere you should have a look to see if there’s anything new.
The address is http://www.buildbettersleep.net
When she approached the Australians about a local drivers license, their response was "we don't know what this "N" is supposed to mean, but just in case we will give you a "P" or provisional license for six months. If you've had no incidents in those six months, we will remove the "P" and issue you a full, unrestricted Australian license."
