I don’t know if this will help anybody else, but it’s worth a try. Yerba mate tea was recommended to me by an alternative doctor. I didn’t hold out much hope, but decided I’d try it–and it’s really improved my sleep. For this past month, I’ve taken hardly any Ambien.
There’s a difference of opinion about whether it contains caffeine: some people say yes, others no; some say it contains something that’s related to caffeine, called mateine, others say mateine is the same as caffeine. All I know is that yerba mate gives me about the same lift I get with green tea, only when I wake up in the middle of the night, it’s much easier to get back to sleep-I don’t wake up with heart pounding and that all-systems-go feeling which I usually have. My doctor said she’s measured her own bodily responses and found that it produces less cortisol. That’s the thing about caffeine: that wonderful lift it gives happens because it raises raises blood pressure, speeds the heart, and stimulates the stress system, and the system may not return to resting place so easily, especially if you’re older Yerba mate seems to be out of my system faster, though there was one day I drank some late in the day and that did seem to interfere with my sleep.
Anyhow, it’s very interesting and definitely worth a try.
How to sort through the hype and hysteria?
As the author of INSOMNIAC, a first person account of living with insomnia, I spent six years researching sleep meds, and concluded that these are not demon drugs, but neither are they harmless. They require thought and attention. No sleep med on the market today is problem-free. None gives deep, natural sleep through the night and keeps on working indefinitely. All interfere with the structure of sleep, so that if we take them continuously, we may be robbing ourselves of the restorative benefits of sleep. Most have adverse effects on memory and coordination. Some may be addictive.
I say, turn to medications as a last resort, after you’re tried everything else, as a final line of action rather than a first. But since I find living on the 2-4 hours sleep that’s my usual lot is just too terrible, I turn to them-quite a bit.
If you decide to go this route, find a doctor who will work with you- no mean feat, since doctors are caught in the same hype and hysteria that infects so much thinking about medications. There’s the pill-happy doctor, on the one hand, who whips out a prescription pad before you’ve stopped talking, and sends you out of the office with a drug that may or may not be right for you; and there’s the censorious doctor, at the other extreme, who makes you feel like a junkey for asking for a sleep aid. It may help to know that hypnotics, as FDA-approved sleep meds are called, are regulated in a way that makes many doctors shy away from them; if your doctor seems irritated with your request, it may have more to do with these regulations than with you. Hypnotics are regulated by the Controlled Substances Act, which categorizes substances according to their medical uses and potential for abuse and dependence. They’re “schedule IV” drugs, which is less restricted than I, II, or III, but still, these are controlled substances, under the jurisdiction of the Justice Department and the Drug Enforcement Administration. FDA guidelines suggest limiting the use of most hypnotics to seven to ten days up to a maximum of a month, yet many of us take them for much longer. Prescribing them for more than a month may put the doctor at legal risk.
Antidepressants -which include the older drugs like Elavil, Deseryl (trazodone), and the newer SSRIs, Paxil, Zoloft- are not “controlled substances,” which may be one reason they’re so often prescribed for sleep. They don’t work for me: they fog my brain, speed my heart, and don’t help my sleep. But they do work for many people. No two people react to a drug the same way-even antihistamines, the staple of most over the counter sleep remedies and of cold medicines like Benedryl, are unpredictable, acting like a soporific for some people and like speed for others. Someday, perhaps, a doctor will be able to take a blood test, assess your DNA, and with this information, be able to tailor a prescription precisely to you. But for now, no doctor can guess how a drug will work for you-only you can be the judge of that. You have to be willing to come back and say, can I try something else? And for that, you need a doctor who’s willing to trouble shoot.
Then, find out what you’re putting in your body. Read the package insert, get on the web and find out all you can about it. Know what category of drugs the medication belongs to, the effects it’s likely to have. (There are user-friendly, reliable Web sites that have information on drugs, listed below.)
The longer acting drugs, the benzodiazepines (Ativan, Valium, Restoril), are more likely to get you through the night, but may also leave you hungover the next day, since they hang around the system longer, and may also be more addictive. The shorter-acting, so-called non-benzodiazepines (Ambien, Lunesta, Sonata), may be out of your system so fast that they don’t get you through the night. But at a low dose, these may help you get back to sleep when you wake up after a few hours. (That’s how I use Ambien. But if you use a med in the middle of the night, be sure you’ve left time for the effect to wear off before you have to swing into action the next day.)
Then, if you continue taking a med for any length of time, keep tabs on yourself. Make sure it’s not affecting your personality or mood. If you begin to feel not yourself, consider that it may be the med. Ambien, though it agrees with me, can have some pretty weird effects: people waking up to find candy bar wrappers and crumbs in their bed, having telephone conversations they don’t remember, driving with no recollection of it. Sometimes this happens because they’ve taken too much of the drug, or have taken it over too long a time, or have mixed it with alcohol, or because they took it before they left the office or the party and drove home. (Never take a sleep med anywhere but in bed, when you are about to go to sleep!) Sometimes it happens simply because they have a bizarre reaction to this drug. “These drugs do things we do not understand,” as Daniel Kripke says, whose website, “The Dark Side of Sleeping Pills,” may put you off them forever.
So try around to find out what works, then monitor yourself-then manage the drug. Take as little as you can to get by with, even if the bottle tells you to take more. The smallest dose is always the best dose. Drugs lose their effect over time, and if you start at a high dose, you’ll habituate faster -and be more likely to become dependent. Try taking a break from the med; consider alternating it with another type of drug, say, a short-acting non-benzo with an antihistamine. Make sure the dose doesn’t creep up. Beware of creative combinations: that’s what did in Jackson and Ledger.
The good news is that there’s a wider choice of drugs than there used to be: the several kinds of antidepressants, the older and newer benzos and non-benzos, the over the counter antihistamines-and this increases the likelihood of your finding something that works. The bad news is that nobody knows what any sleep med does over time-none of these medications has been tested for long-term effects. Only two FDA approved sleep meds, Lunesta and Rozerem, have been okayed for indefinite use, and even these have not been tested for anything like the duration many of us take them.
We’re between a rock and a hard place, when it comes to meds. Lack of sleep is bad for mood, health, and memory; sleep meds may be bad for memory, health, and sometimes bad for mood. Only you can do the risk benefit calculations to decide whether the risk is worth the benefit to you. But if you’re careful, and lucky, you may find a med that turns some wasted, wakeful hours into sleep.
Those of us who have trouble sleeping get tired of hearing the same old advice, the same half dozen rules we read everywhere. Avoid caffeine, alcohol, and big meals late at night. Don’t exercise or engage in stimulating activities near bedtime, such as reading or watching TV in bed. Try taking a hot bath or writing a “worry list.” When you can’t sleep, get out of bed and do something else. Get up at the same time every day, no matter how little sleep you’ve had—and don’t nap. And don’t worry —you’re probably getting all the sleep you need.
As someone who’s lived with insomnia for half a century, who’s spent six years interviewing sleep researchers and fellow insomniacs, writing INSOMNIAC, I found that some of this advice may help some people some of the time, but there is no one-size- fits-all-solution.
About caffeine, alcohol, and big meals close to sleep, the experts are right. Caffeine sets the stress hormones flowing, speeds the heart, and raises blood pressure. The half life of caffeine, the time it takes for half of it to be broken down, is between 3 and 7 hours—so if your last cup was at 1 PM, you still have a quarter of it left in your system at 3 AM. If you drink it daily and are on the slow side of metabolizing it, it never leaves your system—and we get slower as we age, so if you could drink coffee when you were 35, that doesn’t mean you can at 50. A woman between ovulation and menstruation takes about 25 percent longer to eliminate it. A woman on birth control pills takes twice as long, according to a 1993 study by M.J. Arnaud. But if life without caffeine is just too bleak, consider tea, which has about half the caffeine of coffee and has, besides, a substance that damps down the stress system. And if black tea is still too strong, green tea has about a third the caffeine content of that.
Alcohol is confusing. It’s a complex, “messy” drug that works on several systems, acting as a depressant but also stimulating the stress system. But even when it seems to help you sleep, it breaks down into by-products that come back to bite you, which is why you may wake up a few hours later with a bad buzz. And even if you don’t wake up, the EEG shows shallower sleep. You might want to rethink that nightcap.
Avoid big meals close to bedtime—so say the experts, and so say I. Digestion is an active, intense, heat-generating process, not something you want to initiate close to sleep. The consumption of calories raises body temperature, and as a general rule, anything that raises your temperature—like an electric blanket, a warm room—may wreck sleep, since core body temperature needs to decline for sleep to be initiated and maintained.
Exercise, of course, raises temperature in a big way, which is why we’re told to avoid it in the evening. But I’ve found that if I leave a few hours between exercise and bedtime, evening exercise may actually help. When I swim within a few hours of bedtime, I get a lovely wave of sleepiness an hour or two later—maybe for the same reason that a hot bath helps, because it raises the body temperature so that so that the rapid decline that occurs afterward signals the body it’s time for sleep. My swimming tends to be relatively relaxed, however, and a strenuous aerobic workout that close to bedtime might have bad effects. You have to find what works for you.
But in the hours just preceding sleep, you need to find ways of chilling out—I mean, literally, cooling down. This means no more trips to the kitchen, no late night emails or anxiety-provoking conversations or projects, physical or mental, nothing that speeds the heart and raises body temperature. Find some way of making a barrier between the day and sleep. Leave the day at the bedroom door.
The experts tell us we should practice nightly sleep rituals, but the unwinding activities people find are actually more various than expert advice allows. Many people find reading bed or watching TV a necessary part of relaxing. Insomniacs tell me that reading computer manuals, or Emmnual Kant, works beautifully. Not for me—my mind has to be at least somewhat engaged. The New York Times works well, sometimes a novel, though no page-turners or cliff-hangers. And nothing work-related.
My preferred way of unwinding is a DVD. Nothing action-packed or too adrenalin-pumping, though. Chick flicks work best, things like The Holiday, The Devil Wears Prada, The Jane Austen Book Club— pretty to look at and they have happy endings. A friend swears she can’t sleep without watching a half hour of Sex and the City every night. Travel documentaries work well, too, sending me to sleep with visions of other places, other lives, dancing through my head.
Many people have success with worry lists or journal writing as a way of decompressing. Not me: I don’t want anything to do with words, and nothing to do with the computer. I work with words all day long, I have words enough buzzing through my head. Besides, when I write, I conjure, bring to life—the last thing I want to do with a worry. No, give me a chick flick.
“If you can’t sleep, get out of bed and do something else”—this is advice we hear all the time. But it never works for me: when I get up and turn on the light, I’m up for the night. What does sometimes work is listening to a recorded book, which lets me lie in the dark but gets my mind onto someone else’s story. Memoirs work best for sleep, and quiet kinds of novels, but they have to be interesting and pleasurable moment to moment, with characters I want to spend time with, nothing that leaves me hanging on, waiting for what comes next. Listening to a book lets me lie in the dark in a restful state, eyes closed, drifting in and out—and this may be have restorative effects. A series of fascinating studies done in the nineties by National Institutes of Health researcher Thomas Wehr looked at subjects dozing in the dark, and found that levels of sleep hormones melatonin and prolactin remain elevated (prolactin is a tranquility-promoting hormone that’s associated with lactation and that keeps birds still as they brood their eggs).
If you’re lying there listening to the sound of your wheels spinning, though, you’ll get no restorative effects from that— better to get out of bed and do something else. But whether you get out of bed or stay in it, try to see it as a choice, not an affliction. If you stay in bed, tell yourself, how lucky I am not to have to get up, how lovely and restful it is to be lying in the dark, all these nice healing hormones. If you get up, think of that as a choice, too— view it as an opportunity to do yoga or meditation or music or read a few more pages of a novel. And if you end up taking a low dose of a fast-acting sleeping pill for a few more hours sleep, well, okay, that’s a choice, too (just leave time for the morning effects of the pill to wear off). Be glad we live in a time when we have such medications. Generations past did not such a wide range of meds to choose from.
Experts tell us we should adhere to a regular sleep schedule, get up at the same time every day to an alarm, even if we haven’t slept enough. Sorry, there is no way I will sacrifice sleep to regularity. Sleep is such a shy and fleeting presence in my life, and is so essential to my mood and functioning, that, no, I won’t scare it away with an alarm. So my schedule sometimes drifts way late. But I’m an academic, I get to schedule classes late in the day. If your work allows it, if you’re retired or a student or self-employed, why feel you have to march to the world’s time? True, you don’t want to drift entirely out of synch with the world. But people in the not so distant past, as recently as the nineteenth century, slept in segments, and people in traditional cultures today drift in and out of sleep more fluidly than we do. The consolidated 8-hour block may actually be an artifact of industrialization and artificial lightning.
So I say, sleep when you can. As for napping, even a few minutes can recharge the batteries.
“You probably don’t need as much sleep as you think you do” –I’ve heard this all my life. But when you talk to people about their sleep, as I did, writing INSOMNIAC, you find out how different we all are in terms of the sleep we need and how well we bear up under sleep loss. Research that came out earlier this year suggests that our differences are inborn and genetic, and there’s not a lot we can do about them. Scientists at the University of California, San Francisco, found that those who function well on less than six hours have a certain kind of genetic mutation. Researchers at the University of Liege in Belgium and the University of Surrey found that how well people weather sleep deprivation is related to the short or long variant of a gene that governs the timing of sleep.
So don’t tell me I’m getting all the sleep I need. Let me be the judge of that.
For most people, sleep is not an issue: you turn off the lights, you go to sleep, what’s the big deal? I think these are the people who wrote the sleep rules. But if you’re one of the sleep-stressed, like me, it’s a lot more complicated. You need to become a careful observer of your sleep, listen to your body, learn how your sleep reacts to food, drink, light, medications. Figure out what times you sleep best and worst. Read around, get on the web and find out what works for others. Then cobble together a set of practices that works.
There are no ten rules to better sleep. There is only what you can find that works.
Links to 2009 genetic research:
From HuffPo, a suggestion from stress management author Debbie Mandel, from Chinese herbal medicine: “Put feet in a pot of hot water for one minute and then alternate in pot of cold water for 30 seconds. Do this three times. This releases toxins from your feet — … The heat circulates the blood and the cold water reduces the swelling. The cold pulls out toxins in the contractive phase and the heat brings blood and nutrients in the expansive phase.”
Vick’s Vapor Rub on the bottom of the feet, and then put on socks—this also from the Huffington Post.
Here’s something I read in Esquire.com, A.J. Jacobs, “Random Sleep Trick No. 17: Alternative Sheep-Counting:” “Counting sheep is a crock,” and mentions a 2002 Oxford study that shows it actually delays sleep onset. But he (she?) has found “ a mental trick… I invented it myself, but I offer it free here — no trademarks, no royalties. My qualifications: I used to be an insomniac whose mind raced, brooded, and obsessed as I lay in bed. No more. Here it is:
Step 1: Choose a color.
Step 2: Brainstorm a whole bunch of objects that are that color. If you chose green, you can think of green leaves, green beans, green Jets football helmets. And on and on.
Step 3: You must brainstorm in categories. First think of green foods: broccoli, seaweed, the Shamrock Shake. Then move on to green animals: lizards, parrots. Then come up with phrases that have the word green in them: the Green Monster, green with envy, the Green Party,” etc.
It sounds like a lot of effort to me, and effort wakes me up—but if it works for Jacobs, it might work for somebody else.
Esquire, March 25, 2008
AURICULAR THERAPY, stimulating points of the outer ear with seeds or needles. Ear seeds, tiny black seeds of the Vaaccaria plant, are affixed to various points of the ear. One woman says that pressing on the seeds “throughout the day has improved her sleep to the point that she can’t live without them now.”
Camille Sweeney, “A Traditional Therapy Finds Modern Uses,” www.nytimes.com/2008/02/21/fashion/21SKINtwo.html
Along these lines, a reader who’s had serious insomnia was using a WRIST DEVICE to monitor her sleep—when she found herself sleeping better. She thinks she may have happened on a pressure point that brings on sleep. She’s skeptical, but she passes this along:
…am still sleeping better (not good by normal standards). If you can buy a wide Velcro’s watch strap and wear it on your left arm just 3 inches short from you wrist, quite tight. I am sure it can’t be the strap that has changed my sleep but try it (I wouldn’t suggest such a nutty idea to anyone else but I know you have tried some dumb things before!). If it works we’ll patent them and laugh all the way to the bank!
A man who interviewed me for a radio show told me that electromagnetic pollution is a disruptor of sleep. There have been studies about cell phones disturbing sleep.
A device called the COMFORT CLOCK claims to stabilize the destabilizing energies that come from electromagnetic fields.
Richard Shane, who has suffered from insomnia himself, devised a SLEEPEASILY method that he claims can help calm the heart. You know that change in breath that happens just as you’re about to fall asleep? His method teaches you to bring this physiological change on, and thereby induce sleep. He makes a lot of sense.
One study found that babies snugly blanketed (swaddled) sleep longer and wake less often than babies who aren’t. There is even a “swaddler/sleep sack” you can buy, “created after the inventor watched her daughter suffer countless sleepless nights because of the involuntary startle reflex, known as Moro Reflex.” Maybe grown-ups need SWADDLING, too. I talked to a woman who told me that wrapping herself tightly in blankets helped her sleep. Maybe anything that makes us feel less free-floating in the universe is a help.
Things I tell myself: “You can rest now,” I repeat this, like a mantra. “The day is done, no more work, you did good.” Okay, I maybe not so great, but forget that for now— be kind to yourself, the day is done, you can rest.
It sometimes works. Almost.
Here are some things readers have written me about or that I’ve heard about:
A megadose dose of Vitamin D – a couple thousand mgs.
CRANKY BABY: an aromatherapy spritzer that promises to transform babies from cranky to sweet-tempered. It combines chamomile, tangerine, and sweet orange. This woman swore it did wonders for her.
A few teaspoons of lemon juice in warm water. This reader added that even if it doesn’t help your sleep, it’s good for digestion.
Cherry juice, tart, concentrated. I came across this at an exhibit at a sleep conference. It’s a natural source of melatonin, which makes some people sleep. I did seem to sleep better for a few nights,but then, I bounced back to my usual 2-3-4 hours. But I love the taste, and it’s helped my arthritis, so I’m a convert. It’s a powerful anti-inflammatory— if you’ve got joint pain, it’s definitely worth a try. And since we lose melatonin as we age, and melatonin supplements can be a bit tricky, I like having a natural source, even though it doesn’t do a thing for my sleep. The form I drink is CHERRYPHARM, but there are lots of sources on the web. And no, I’m not on the take.
Nor am I on the take from BIOZZZ. This is something else I came across at a sleep conference exhibit, picked up some samples and took them home and tried them. It gave me an unusually good night’s sleep. It delivers hefty dose of tryptophan. I can’t say it worked the next night, but I haven’t ruled it out.
Homeopathy, for which there seems to be no scientific evidence, still seems to coming up as helpful. In Europe, it’s taken more seriously than it is here. A physician wrote me from Paris that he’d been looking into “gemmotherapy remedies.” (This sounds more like herbal medicine than homeopathy: it uses remedies made from the buds and shoots of trees and shrubs.) His mother and daughter were both having sleep problems, and with a remedy called NOCTIGEM, they’re now sleeping much better.
He referred me to an online shop in Belgium:
I tried it, and it did help me get to sleep, but it didn’t help me stay asleep, which is my main problem.
The active ingredients are listed as fig and linden tree: ”Linden tree, which possesses the calming properties of the flower, as well as the cleansing function of the underside of the bark (sapwood); together with that of the fig which has profound effect on the nervous system as a whole.”
Might be worth a try, though it’s pricey.
A friend who’s had longtime issues with insomnia told me he’s discovered the magic pill for him, Safeway brand over the counter, a blue pill. I looked at the label and it’s a simple antihistamine, same stuff that’s in Benedryl. I take Benedryl every time I get a cold. I do love the sleep I get for 2-3 nights (though I don’t like the morning grogginess), but then I bounce back to my same old broken sleep. But my friend doesn’t seem to be getting used to it. Since we’re all so different in the way we respond to drugs, this might be a simple, inexpensive and fairly harmless thing to try. (I think it’s probably the same as the Costco brand, and probably a dozen other brands…)
More next week….
I threw out a lot of suggestions, in Insomniac, for things to quiet a racing mind. I wrote about “mind machines,” with earphones that pump electronic music at you and goggles that flash pink and green –you can barely sustain a thought with these, let alone a racing mind. I wrote about “brain music” that’s made from your EEG, and “bedtime beats,” music set to a slower beat, that claims to lull listeners to sleep. I wrote about a visualization technique I made up that combines visuals with counting; on bad nights it doesn’t do a thing, but on some nights, it slows my heart and breathing and eases me to sleep.
It’s funny, the things people write me that have worked.
A reader wrote me that wearing a dark sock over the eyes helps her get to sleep. That’s so simple a technique that I almost didn’t put it in the book!
Another reader wrote me that the vitamin cocktail I describe on p. 290 had transformed his life. It’s an elaborate recipe, not something you can throw together from ingredients you have around the house, and I confess, I’ve never tried it. But it worked for him.
I’m going to respond to a few posts people have left.
Post left by “nodnoble,” June 4, 2008, about transcranial magnetic stimulation (TMS).
This seems like a noninvasive way to induce deep sleep. Magnetic fields can pass easily and harmlessly through the skull, and with a TMS instrument, pulses can be directed to specific areas of the brain to make them more or less active. The method has worked to dispel the “inner voices” of schizophrenics and has had success with clinical depression; researchers hope that it may even someday replace electroconvulsive therapy. It has been used to produce what looks like slow wave sleep, the deepest kind, by Giulio Tononi and others at the University of Wisconsin, Madison. I too would like to know why it isn’t on the market for use by insomniacs.
Thanks, Matt K, for posting about writing as a way to get to sleep. Writing a worry list is one of the techniques recommended by the sleep doctors. I’ve had several people tell me that writing in a journal helps them leave their worries at the door. It doesn’t work for me: writing is too much like what I do for work; and when I write, I conjure, which is not something I want to do with a worry. We’re all very different.
Readers have written me that they’ve found books on tape helpful. Thanks, Gary, for that list of books, and for pointing out how important the sounds of the voice is.
Somebody asked, why tapes and not MP3? I need something I can work in the dark, with my fingers. With an old-fashioned walkman, I can turn the tape over, run it back or forward, without turning on a light or looking at a lighted dial. Anything that isn’t absolutely simple wakes me up. Maybe there’s a way of using an Ipod or MP3 in the dark that I haven’t found. I hope so, because I’m running out of tapes and they aren’t making any more.
Somebody wrote that the click at the end of the tape wakes her up. If you use earplugs and white noise that muffles the click.
Check in next week for more things to help you sleep. I’m compiling a list…
Insomniac was shortlisted for the Gregory Bateson Prize, Society for Cultural Anthropology, for being ”interdisciplinary, experimental, and innovative.”
Check out this cool article by Rubin Naiman, “How Cool Is Your Sleep?” It’s about how important it is to cool down, to get good sleep.
Of all the useless advice I’ve ever had for insomnia—and there’s been plenty— the most irksome is this: you’re probably getting all the sleep you need, don’t worry about it—just buck up and get a grip, change your attitude, you’ll be fine. Actually, I’m pretty clear about how much sleep I need; when I feel sleepstarved, I really am.
When you start asking people about their sleep—as I did, writing INSOMNIAC—you find that they vary enormously in terms of how much sleep they need and how they weather sleep loss, and there’s not a lot they can do about it.
A new study at U.C. San Francisco suggests that whether we need a lot or little sleep is not about whether we have a positive or negative attitude — but whether we have the DEC2 mutation.
Dr. Ying-Hui Fu and her colleagues looked at a family in which the mother and daughter require significantly less sleep than other family members, 6 hours to their 8. They found that the DEC2 gene was mutated in the short sleepers. They then genetically modified mice to carry the same mutation, and sure enough, the mutated mice slept on average two and a half hours less than the normal mice— with no noticeable differences in health or performance. (Science, August 14)
Another study, lead by Pierre Maquet at the University of Liege in Belgium and Derk-Jan Dijk at the University of Surrey, suggests that whether we’re clobbered by sleep loss or remain perky and functional is about whether we carry the short or long variant of the PER3 gene. People with the short variant perform better on cognitive tasks after sleep deprivation than those with the long PER3 variant. Brain imaging showed their brains were more active after the sleep deprived night, and this seemed to be correlated with better performance. (Journal of Neuroscience, June 24)
It’s no surprise. So many sleep behaviors turn out to be genetically programmed. Scientists have long known that identical twins, even when not raised together, have sleep patterns more similar to one another than do non-identical twins or other sibling pairs, in terms of bedtime, length of sleep, length of time it takes to get to sleep, and even quality of sleep. Scientists now know which genes are associated with morningness and eveningness.
So when we insomniacs complain about being clobbered by sleep deprivation, please don’t tell us we’re getting all the sleep we need and if we changed our attitude we’d be fine. And if you’re one of those fortunate people who does well on little sleep—and there are probably lots of doctors who are— don’t be so hasty to judge the sleep needs of others by your own needs. We’re all very different when it comes to sleep and sleep need, and these differences are no more to anyone’s credit or discredit than blue eyes or blond hair.
“Studying Insomnia,” Nature Medicine, 15, 481, 2009
“This book is written with clarity, empathy and knowledge. Carefully collected and updated scientific data are intermingled with experts’ opinions and patients’ reports. The result is an intriguing journey into the objective and subjective worlds of insomnia and insomniacs, a ‘combined view’ that makes the book unique….
INSOMNIAC will be of considerable interest for those looking for a comprehensive and well referenced book on insomnia. Both patients and sleep specialists will find information, inspiration and consolation from the unique perspective of an author, an insomnia sufferer herself, who seems to know more about insomnia than do many physicians who care for the people with this disorder.”
…to the sleep meetings, that is, SLEEP2009, Seattle. (No, not to sleep, not at a conference— I was as sleepless in Seattle this year as I was in 2002, as I was all the other years… this is my 8th annual sleep conference.)
But there’s been some progress since 2002. There’s more recognition that insomnia may be a risk factor for depression. The old story was, you had insomnia because you were depressed. Now there’s some understanding that you may be depressed because you have insomnia. (It’s nice to see science catch up with common sense.) And there was more discussion of the neurophysiology and genetics of insomnia, which is great, because that’s where I think the breakthroughs will come from.
Eric Nofzinger at University of Pittsburgh has been doing neuroimaging studies that find that insomniacs’ brains are metabolically very active during sleep, working overtime—no surprise to those of us who live with the condition. He and his colleagues tried putting a cooling device on the scalp, and 5 out of 8 insomniacs showed reductions in brain metabolism and a faster drop in core body temperature around the time of sleep onset (a temperature drop is necessary for good sleep). 75% of these subjects reported sounder and more refreshing sleep.
Granted, this was only 8 insomniacs and not all of them responded, but it might be worth a try. I wonder about those cooling caps for chemotherapy, designed to prevent hair loss (since cooling slows metabolism). That might be a way to go. Or, try wearing an icepack to bed! Can’t hurt…
NEW MEDICATIONS in the works…
The mainstay medications most of us take, like Ambien, Lunesta, Restoril, work on the GABA system, the inhibitory neurotransmitter of the brain.
· A new medication will target the hypocretin/orexin system, the wakeup neurotransmitter narcoleptics have too little of. It may be that insomniacs have too much of this, or too active a system, and damping it down will give us better sleep. An expert I talked to thought it might be more “natural” than the knockout current remedies provide; he says it may be on the market in 4-5 years. Another said, “yuck, induced narcolepsy.”
· Another drug, eplivanserin, works on the 5 HTT, serotonin receptor. This has been in development for awhile; I’m not sure what’s taking it so long to get to market…
· And there’s also a new version of an oldie but goodie that seems close to FDA approval, zolpidem in nasal or sublingual (under the tongue) forms, for faster acting, middle of the night usage. I’m interested in this, since middle of the night is when I usually take zolpidem.
NIGHT EATING SYNDROME
… is when you consume half your calories after 8 PM. I heard a paper that reminded me how bad this is for sleep, how it destabilizes insulin and hormonal balances, especially the stress hormones and hunger hormones, and makes for frequent nighttime waking.
They have a support group, unlike insomniacs:
Hearing about the dangers of night eating reminded me of an email I got from a guy was certain his sleep was screwed up by the supplement Juvenon—and it never did return to normal. Supplements can be scary, as I wrote in INSOMNIAC—red flag this one! After many a trial and error, he’s found that the only way he can get any sleep at all is by skipping dinner. He emailed me:
Russians have a saying to the effect that one should “eat breakfast yourself, share lunch with a friend and give dinner away to your enemy.” The link is http://english.pravda.ru/society/family/26-03-2006/77863-eat-0
On the other hand, there are people who find a big plate of pasta soporiphic. Me, I know I’m better off when I stop eating 3 hours before sleep. Now if I could only kick the after-dinner popcorn habit….
Speaking of kicking habits, I gave up drinking, May 2008. Reading over my blog from New Year’s Eve 2007, I have to tell you, the champagne days are over. Even the wine glass in the author photo is out of date. I wish I could tell you it’s transformed my sleep, but it hasn’t. It has maybe made my sleep a little bit better, kinda, sorta; but I was hoping for more. So alcohol goes on that long list of things that can make sleep worse, though giving it up doesn’t seem to make sleep better. Go figure.
WAGES OF WAR
There were a few papers at this conference about soldiers’ sleep, or lack thereof. Guys come back with PTSD or traumatic brain injury, both of which are disastrous for sleep.
Prazosine, 2-5 mg., seems to help sleep and reduce nightmares. I have no idea what else it does, what side effects it has; and when you stop it, the symptoms come back.
Imagery Rehearsal Technique, a way of rewriting your dreams, sounds like a more effective long-term therapy.
Also, I’ve read that people who learn to do lucid dreaming can sometimes rescript their nightmares.
Speaking of dreams, there was hardly anything at this conference about dreams—and there has been hardly anything about dreams in all the years I’ve been going to these meetings. At the one dream presentation I found, the speaker began by commenting that nobody’s working on dreams anymore, except for nightmares related to PTSD. He said he gave a questionnaire to his patients, asking whether they make use of their dreams in their life. Very few said they did, and those few tended to be involved in creative work: writers, screenwriters, actors had the highest dream recall and made use of their dreams.
What I want to know is: do creative types remember their dreams because they’re creative, or are they creative because they remember their dreams? If creativity is linked to dreaming, then it seems sad and a little risky to lose our dreams. We’re a society that doesn’t have much use for dreams. Everyone prides themselves on how little sleep they need: who needs sleep, who needs dreams? I need them. I hate it when I go long periods of time without remembering my dreams, as happens when my life’s too busy or when I take too much sleep medication.
On the other hand, I know perfectly productive and highly creative people who have no converse with their dreams. Go figure…
“Study links primary insomnia to a neurochemical abnormality in young and middle-aged adults. The study is the first to show a specific neurochemical difference in the brains of adults with primary insomnia.”
At last! I knew it, I said it in INSOMNIAC: insomnia is not (necessarily) about psychopathology, it’s about neurophysiology I always knew there was some neurobiological/neurochemical difference between me and people whose sleep comes down like a black-out curtain, sweeps them under like a wave. Here’s what I wrote:
“What if, in the not too distant future, people are saying, ‘we used to think insomnia was [about habits, attitudes, psychopathology]… but we now know there’s too little of a crucial neurotransmitter, some substance that’s not being produced… some glitch in the brain’s extraordinary circuitry that leaves insomniacs without the neurological wherewithal to transition to or maintain normal sleep’?”
I knew the research would bear this out. I didn’t know how soon.
John Winkelman, lead researcher, says this “may increase the legitimacy of those who have insomnia.” Yes, it will! Very exciting research! Go, Winkelman!
Check out these links:
As an insomniac, I’m often asked, “what do you do when you wake up in the middle of the night —get up and work?” Work? Ha! People have this notion that insomnia gives you all this extra time to get things done. No way. I’m braindead on 2-3-4 hours sleep.
Experts tell us to get out of bed, go to another room, and do something else. But it’s depressing to out of bed in the middle of the night, and not all of us have a comfy extra room to go to. Besides, if I get up and start doing anything, if I even turn on a light, it wakes me up more and destroys all chances of getting back to sleep. But the experts are right, lying in the dark listening to the sound of your wheels spinning is no good, either. I may wake up without a thing on my mind, but if I lie there long enough, my mind will find something, and at that hour, it’s not likely to be good.
So I reach for my walkman and earphones and put on a book on tape (and I do mean tape, not CD or iPod, which are useless for this kind of listening). Just knowing there’s a novel or memoir to listen to makes the waking less grim. Some of these books are so marvelously performed that they become like a theater in my head. Worlds open up, scenes play themselves out, and since my day job is teaching literature, it’s a way of keeping up. But more than useful, it’s a pleasure, and sometimes even a way of getting back to sleep.
Listening to books may work as well those punishing measures sleep experts advise. Research suggests it does. One study instructed subjects who couldn’t fall back asleep after 10 minutes to sit up in bed and read or listen to the radio or watch television. It found that their sleep was significantly improved after four weeks and remained better a year later—and they didn’t have to get out of bed. The key was, they got their minds off their own thoughts. I prefer listening to reading because it lets me stay under the covers, warm, snug, and in the dark, which keeps the melatonin and other restful hormones flowing.
But it’s not easy to find a book that’s good for sleep. It takes just the right kind of story, interesting enough to engage the mind but not so interesting that I need to stay awake to see how it comes out. No pageturners or cliffhangers, nothing too exciting (Seabiscuit got transferred to the car). Nothing with violence or physical awfulness. But it can’t be boring, or my mind slips back to my own story. The reader must have a soothing voice and not rush through. And no shouts or songs or that dumb mood-setting music—that startles me awake. Those tapes get moved to the car, or ditched, if the music’s obnoxious enough.
Novelists who work especially well for me are Jane Austen, Anita Brookner, Penelope Lively, Ian McEwan. Memoirs work beautifully because they’re not plot-driven: Nuala O’Faolain’s Are You Somebody? Russell Baker’s Growing Up, Alexandra Fuller’s Don’t Let’s Go to the Dogs Tonight. The language is interesting, the characters are engaging, and if I fall asleep and miss a scene, I just wind the tape back the next night and find where I left (which is why tapes are better than the new technologies). If the writing is good, I’m happy to listen again.
I get to know some of these books quite well, though in a lopsided sort of way: the first part of a tape, I hear over and over; the last part, I may never hear at all. My friend Carol Neely listens to books to sleep by, too, and we’ve talked about writing blurbs: “this book is great for putting you to sleep.” It doesn’t sound like a compliment, but it is. It means the book is sufficiently interesting moment to moment to keep the mind engaged, so you’re not hanging on to find out what comes next. Carol loves biographies, Doris Kearns Goodwin’s Franklin and Eleanor and David McCullough’s Truman— “they go on forever,” she says, “they’re well written and interesting and you know how it turns out, so there’s no suspense.” But there are so many different kinds of things recorded— histories, romances, inspirational— that there’s something for everyone.
Eric Zorn, columnist for the Chicago Tribune, uses cassette recordings of talk-radio programs to fall asleep to. “I find those meditation thingys very distracting—‘think of a peaceful beach…’—and too much work. Try something that truly takes your mind away, like a big screaming match on immigration or abortion or gun control.” He says, “I try to pay attention the conversation, follow it carefully, engage in the topic. The next thing I know it’s morning and I am rested and refreshed.” A respondent to Zorn says, “Nature programs work, too. I have a tape about backyard birdwatching that I’ve never seen more than five minutes of.” One man swears by the Golf Channel. Not me: I need a story.
I’ve scandalized purists, defending listening like this—an English professor, letting down the cause of reading! But I’m not letting it down. Western literature began as an aural form, with Homer reciting The Iliad. Shakespeare’s plays were written for the stage, not the page— most of his audience didn’t even know how to read. Surely it’s the prejudice of a print-bound culture to imagine that reading is superior, when aural forms have this long and illustrious tradition, and the sounds and rhythms of words have a far more elemental power than print on a page.
“There’s not a parent who doesn’t know the value of a good snoozy story to help lull the little ones to sleep (or make that cranky transition a little easier),” writes a New York Times reviewer of children’s books. It’s a primal pleasure, being read to—it evokes what Anne Lamott calls “the listening child.” I’m hooked—and it’s a technique for coping with insomnia that I can recommend unequivocally. It can’t hurt you, unless you blunder onto a page-turner and lie awake all night to find out who dunnit; then you’ll curse me. Otherwise, it’s harmless; no side effects.
Let other people be bookworms, I’ll be a tapeworm. (I wish I could claim that line, but it’s David Sedaris’. Can’t tell you where he said it, though—I heard it on tape.)
10-15% of the U.S. adult population suffers with insomnia chronically. Yet in 2005, the NIH (National Institutes of Health) spent a mere $20 million researching insomnia. That same year, Sanofi Aventis spent $123 million advertising Ambien.
I’ve had insomnia as long as I can remember. I remember my parents trying to wrestle me to bed at what they called a “normal” hour, meaning any time before 1 A.M. “But I can’t sleep!” I’d wail. “Nonsense,” said my father, “of course you can sleep. “Everyone knows how to sleep. It’ s the most natural thing in the world—just close your eyes and relax, you’ll get sleepy. If only you’d listen to your mother and go to bed earlier. If only you wouldn’t get so wound up.” So it was something I was doing wrong, some obstinance of mine that I could change if I would.
My father was a normal sleeper and to the normal sleeper, sleep is “the most natural thing in the world.” He was a doctor, an old-style family practitioner who carried a black bag and delivered babies at home, one of a heroic vanished breed—but that didn’t mean he knew a thing about sleep. Sleep was no part of the curriculum when he was in medical school; it is barely a part of medical school curricula today, when doctors get as little as an hour or two instruction in sleep or sleep disorders. So the advice I hear from doctors these days is a lot like the advice I used to hear from him. “Just lie there and relax,” “don’t worry,” “go to bed earlier.”
What I mainly hear is that insomnia is a psychological problem, that it’s caused by worry, stress, depression, anxiety, some kind of neurosis or psychopathology. When I protest that I’m not particularly depressed or anxious, except about my sleep, that my lifestyle’s no more stressful than that of people I know who sleep fine, I’m offered an antidepressant. When I say, I think it’s hormones, doctors aren’t interested in my hormones. It was as though they already know, they’ve made up their mind, that it’s a psychological problem, something I could change if I’d change my attitude or ways. I then get told to avoid caffeine and alcohol, get more exercise, take a hot bath, warm milk, sleep in a dark, quiet room.
So I decided to find out what is going on, that I’m still hearing the same advice I heard fifty years ago. I started talking to the researchers, to find out about the state of the science, and talking to the people who live with the condition, to find out what they know. I think that people who live with conditions have inside information about these condition. We live in our bodies. Women have always known that hormones affect sleep, that insomnia is worse at certain times in the monthly and life cycle, though it took researchers till the late nineties to catch up to this realization. If someone had asked us, they might have figured it out much sooner.
I wanted to hear what insomniacs have to say, their hunches about how they came by insomnia, what they’ve found that works. I tracked down everyone I’ve ever heard of or known who has insomnia, friends, friends of friends, relatives of friends, acquaintances, colleagues, students. I placed ads, I spent late night hours on the Web, surfing message boards, blogs, newsgroups. And I learned that, sure enough, insomniacs have fascinating ideas about where the problem came from, and wonderfully imaginative ways of dealing with it.
I started going to the sleep meetings. Yes, there are such things, and they’re a big deal—more than 5000 people attend the annual Association of Professional Sleep Societies, where scientists, physicians, psychotherapists, nurses, geriatricians, social workers, epidemiologists, sleep technicians, drug company representatives, gather from around the world to share the latest in research and treatments. At these meetings I learned how little is actually known about insomnia—and how little is known about sleep, for that matter. I realized that insomnia can’t be written off as a psychological problem, when so little is known about it, and when so much about sleep behavior—how much sleep we need, whether we’re morning or night people—is inborn and genetic.
I wrote the kind of book I wish I’d had all these years dealing with insomnia, a guide through this territory that normal sleepers barely know exists. Insomniac is not a self-help book, but a self-enabling book, says an Amazon reader. I don’t offer a “program” but I do describe things people find helpful, ways they might think about their problem and approaches they might try, a potpourri of methods and approaches gleaned from living with the condition and talking to others who live with it, not listening to “experts” who’ve never had a sleepless night.
Some of what the experts tell us is very true and important, like being careful about caffeine and alcohol. But nobody can tell you “the sure rules to sound sleep.” You have to find out for yourself what works for you. Experts say, don’t read in bed or watch an exciting DVD close to bedtime. In fact, many insomniacs find that reading in bed helps them sleep—and I find that a DVD helps. And the more dramatic and vivid it is, the more likely it is to send me to sleep with visions of other places, other lives, dancing through my head—and all the more likely it is to help me sleep. (Nothing violent or too depressing, of course.)
There are many routes to insomnia and many routes away from it, ways as individual and idiosyncratic as we ourselves are. Different strokes for different folks. That goes for meds, too. Don’t assume that the first drug your doctor offers you is going to do the trick. I’ve learned about managing sleep medications through a long, painful process of trial and error. What I write about meds may spare others that pain.
You have to find your own way. Do your own research. Read widely, my book and other books and what’s on the web—find out what works for other people, learn all you can. Try things out, then cobble together something that works for you. There are no one size fits all solutions. There is only what you can find that works.
And communicate. Come out of the closet. Let people know—friends, families, employers—that this is a serious problem, seriously disabling, that it’s not going to go away with a hot bath or warm milk.
“Maybe sometime in the future, around the year 2000, say” wrote Douglas Colligan in Creative Insomnia, in 1978, “we’ll have toll free hotline number 800 NO-SLEEP for the National Information Network of Insomniacs Anonymous. It’s a brutal fact of life that while people who are victims of everything from schizophrenia to hay fever have some group to turn to for help, the insomniac has to rough it alone.” I wonder, if Heath Ledger had had such a hotline, might he have reached for the phone instead of for another drug…
But the year 2000 is long past, and no hotline exists. Insomniacs still have no patient-organized advocacy groups to put pressure for more research, no support groups other than a few on-line chatrooms. There are national organizations for sleep disorders that are far rarer than insomnia—narcolepsy, apnea, and restless leg syndrome—and for just about any other problem you can name, but there are no patient-organized groups for insomnia.
Have we been so talked out of our experience, so shamed out of it, that we’re not sufficiently on our own side to organize on our own behalf? Maybe it’s time we find our voices.