Common sleep problems and solutions

by Ronald Hoffman, M.D., CNS

Short-term insomnia

"Every time I fly to Europe...every time my annual report is due...every time I sleep in a hotel..." Short-term insomnia is easily identifiable, has a specific cause, and lasts a few days or at most a few weeks. It doesn't have a major impact on health or work. One common version is known as "Sunday night insomnia." An individual sleeps late on the weekend, and the sleep cycle shifts slightly so that by Sunday night you don't fall asleep as early as you want.

Solution: By waking earlier on Saturday and Sunday morning, you can easily correct the problem.

Drug or alcohol-related insomnia

"A couple of drinks put me to sleep, but then hours later I'm awake." This is a common complaint among drinkers. Alcohol temporarily depresses the nervous system, but it is metabolized rapidly and causes a rebound excitation a few hours later. A person may awake with a start. A lot of people don't realize they have this problem and rely on a nightcap for sleep. (It's the flip side of relying on coffee for energy.)

Solution: Cut out the alcohol. Improvement should occur in a few weeks.

Many drugs can have the side effect of causing sleeplessness -- for example, steroids, thyroid hormone, decongestants that contain stimulants, and asthma medications. In addition, nutritional deficiencies due to long-term use of medications can cause sleep problems.

Solution: Drug dosage can be adjusted, or the time of day a drug is taken can be changed. Nutritional and vitamin status should be tested and deficiencies corrected. Quality sleep will often return.

Insomnia caused by caffeine and nicotine

The most common "drug-related" causes of insomnia are not prescription drugs. They are nicotine and caffeine. Caffeine can interfere with sleep up to twenty hours after you consume it. About 80 percent of adult Americans are addicted to a cup of "heavenly" coffee or tea. Caffeine is also present in colas, chocolate bars, and cocoa. Even headache remedies and diet pills contain caffeine. And the truly interesting aspect of caffeine is that it can cause both insomnia and sleepiness. I've seen countless patients who had trouble getting out of bed in the morning, until they eliminated their caffeine. In response to caffeine, the body's nerve cells fire more rapidly, giving a feeling of alertness and energy. Unfortunately, a crash must follow the high, and caffeine users interpret that crash as a sign that more caffeine is needed. Finally, the store of neurotransmitters may be depleted and exhausted, and a person may feel perpetually tired. The person may become so accustomed to feeling tired that he assumes it's normal.

Similarly, nicotine can alter your energy patterns, locking you into a constant pattern of stimulation from cigarettes. In addition, cigarette smoke contains high amounts of carbon monoxide, which can impair your tissue oxygenation. Cigarettes, like caffeine, can leave you wired but tired.

Solution: Cut out caffeine and/or smoking. I don't even recommend decaffeinated coffee, because it keeps the taste for coffee alive. Switch to herbal teas or to other energy boosters like ginseng, ginger, and licorice. At night, use calming herbs like valerian, hops, and passion-flower.

Circadian rhythm insomnia

We all have certain inborn circadian rhythms. Our body clock, our temperature, and the fluctuation of certain hormones seem to respond to the rhythm of the day, and of light. In fact, we have a gland in our brain, the pineal, which seems to respond specifically to the absence of light by releasing a hormone called melatonin. Sunlight inhibits melatonin. Darkness lets it flow, and so it usually peaks in our bloodstream at about 2:00 am. When circadian rhythms are forcefully shifted, our body tries to adapt, but it is not always successful. Melatonin production may veer out of control, and the body clock may become so disrupted we have trouble sleeping.

A common form of this that most of us have experienced is jet lag. For the first few days after flying to Europe, we may find ourselves sleepy during the day, and wide awake at 3:00 am. We may feel groggy, disoriented, irritable, or depressed.

Another instance of circadian problems: working the night shift. About 25 percent of American workers have work shifts that are not nine-to-five. The most difficult schedule for the body to adapt to is a changing work shift.

Even if you aren't flying off to Asia or working the night shift, you may have a profound sleep disorder simply because you're an urban or suburban dweller. You may be suffering from the same disrupted rhythms and light deprivation that a night worker suffers from, because you are constantly working and living under artificial light. The natural cycle of the body seems to be about twenty-five hours. (That's why we get a boost in the fall when we set the clocks back one hour.)

Solution: Try to work by day under natural light, in an office with windows. At night, if you are an urban dweller, make sure your shades blot out the light of cities. Allow your brain the peace of total darkness. If you are a shift worker, try to change to an earlier shift. If that's not possible, try to work regular hours.

Melatonin extracts, taken at night, may help regulate the body clock. One study of individuals flying to Europe found that taking melatonin for several days before their flight eliminated much of the impact of jet lag.

The newest treatment for circadian shift problems is simple, safe, and effective. The solution? Expose the individual to light that simulates sunlight. This is a treatment commonly used in treating a form of winter blues or depression known as seasonal affective disorder (SAD). The inner body clock can selectively be manipulated by using bright light.

Sleep facts

• Every nuclear accident reported so far anywhere in the world has occurred on the night shift, when people are tired.

• Most highway accidents take place between midnight and 6:00 am and are fatigue-related. Their rate is nearly triple that of accidents occurring at noon or 6:00 pm.

• People who suffer from severe sleep apnea have more than twice as many car accidents as the general population.

• Fifty thousand car accidents a year occur because drivers fall asleep at the wheel.

• We sleep less now than we did a decade ago, according to data from a Japanese study. In 1970 we slept an average of 7.5 to 8 hours a night. In 1990 we slept an average of 7 to 7.5 hours a night. Nobody knows why this is so, but it may be a result of a faster-paced life, in which we juggle many responsibilities.

• Fifty percent of the elderly suffer from insomnia.

• The average person sleeps 220,000 hours in a lifetime.

• The average healthy sleeper moves forty to sixty times each night.

• Nearly 40,000,000 North Americans snore occasionally.

• The life span of a pillow is supposed to be at least two years.

• Fifteen percent of people sleep in the nude.

• The highest sound level of a snoring sleeper ever recorded is 90 decibels.

• Fifteen percent of children under twelve sleepwalk at least once.

• Louis XIV of France had 413 beds.

• Mark Twain's advice for insomnia was: "Try lying on the end of the bed, then you might drop off."

Sleep clock problems

Early to bed and early to rise, the old saying begins. Another circadian rhythm disorder is linked to "sleep phase." Young people tend to suffer from this problem, where they can't fall asleep at night and can't get up in the morning and are tired all the time except at night. Often this is because of hours kept while in college (late nights and late mornings). Though they may complain of sleep problems, if they happen to go to bed late on a weekend night, they have little trouble falling asleep. Sleepiness may strike them about 2:00 am after years of training themselves to adapt to late-night rhythms. The typical solution may sound paradoxical: go to bed later and later each night. This "moves" the body clock forward. Each night, the individual must go to sleep three hours later than the night before. It is a hard schedule to follow, but within a week the body clock will have moved up to a reasonable bedtime (say, 11:00 pm).

The opposite problem often occurs in older individuals. They wake up in the early-morning hours completely alert, and feel exhausted in the late afternoon and evening. In other words, they tend to get tired long before their usual bedtime.

Solution: Once again, light therapy may be the new, twenty-first century solution to the above problems. The prescription: bright, full spectrum light an hour every evening for those who fall asleep before their bedtime, and bright light an hour every morning for those who can't fall asleep until hours after their regular bedtime. The light now available does not contain UV rays. It is worn in a device strapped around the forehead so that it does not shine directly into the eyes, allowing the wearer to go about normal activities.

Restless legs

Some people suffer from creeping, crawling, and aching sensations in their legs, or twitching of the legs that wakes them. This condition is also known as nocturnal myoclonus. One patient of mine slept only one hour a night and complained of horrible sensations of bugs crawling on her legs. She had been inaccurately diagnosed as having a psychiatric disorder. Restless-legs syndrome can be associated with pregnancy, anemia, and other problems.

Solution: Nutritional supplements that help treat and often cure this problem include magnesium, potassium, calcium, vitamin E, and folic acid. Sometimes a patient's requirements for these nutrients can be enormous. One well-educated patient came to me and explained that she had been taking folic acid for restless legs but it hadn't helped. We gave her an intravenous drip with a small amount of folic acid, and her symptoms immediately vanished. However, her oral requirement for folic acid turned out to be sixty times the amount in the drip. I often find this to be the case: when a vitamin goes directly to the bloodstream, it can rush to where it is needed. When it must be digested and absorbed, much of it may be lost because of low hydrochloric acid or lack of certain enzymes. Oral supplements, therefore, sometimes need to be extremely high.

Breathing disorders

Sleep apnea, as has been discussed, is a common cause of insomnia. And sometimes it doesn't result from the patient's snoring. I couldn't solve one woman's sleep problems until I brought her husband into the office and he admitted to snoring. His snoring didn't wake him, but it woke his wife countless times a night. Her sleep was light and disrupted, but in the morning all she knew was that she was tired. She had no memory of repeated waking because of her husband's snoring.

Solution: There are many possible solutions to sleep apnea. If the snorer is overweight, losing weight may help eliminate some of the fat in the throat, thus clearing breathing passages. Cutting out nighttime alcohol and taking an antihistamine or decongestant during allergy season can help. In addition, a device called Snore Guard that keeps breathing regular is worn in the mouth at night.

When sleep is all in the mind: problems and solutions

Sometimes insomnia is related to anxiety about insomnia. An initial period of stress may lead to sleeplessness, and then the sufferer begins to worry about lack of sleep, perpetuating the problem. In this case, it helps to restrict bedtime hours. If a person is sleeping only four hours a night, he can set bedtime hours of 3:00 am to 7:00 am, for instance. Within two to three weeks, he should be falling asleep more easily, because bedtime is no longer associated with tossing and turning. When he is sleeping more efficiently, he can increase the time in bed by fifteen minutes each night.

Hygiene: an effective sleep solution

If the word "hygiene" sounds like clean sleep, it is. And it is a term commonly used among sleep specialists to indicate setting the conditions for undisturbed slumber.

The first injunction: The more you worry about it, the worse it gets. Even thinking about sleep can cause you to become anxious. Picture the exhausted would-be sleeper, lying in bed with a tensed, rigid body, trying to force sweet sleep to overtake him. It's a contradiction in terms. Sleep cannot be willed. Often sleep needs to be set apart from everything else in life.

• Try to keep your sleep schedule consistent. Plan regular hours of sleep time every day.

• Eliminate caffeine and alcohol, particularly at night.

• Don't exercise or start involving yourself in highly engaging mental tasks near bedtime.

• Don't go to bed hungry or after eating a large meal. Eat a light snack before bedtime or drink a glass of warm milk, which contains tryptophan, an amino acid that is a known sleep inducer.

• Tell your spouse, bedmate, or yourself a relaxing bedtime story. My favorite ones are about my turtle. My wife often asks me to tell her a turtle story, which usually puts her to sleep long before I nod off.

• Take a hot bath.

• Make the bedroom a bedroom, a place to sleep. Don't read or watch TV in bed. Remove all other stimulants from the bedroom, including work and bills.

• Don't nap during the day. Confine your sleep to certain nighttime hours.

As you may have noticed, I've hardly talked about the most common solution to sleep problems: sleeping pills and tranquilizers. As a rule, I don't advocate them. And recently, I felt I was proved right, in the case of the enormously popular drug Halcion. This drug was marketed as a panacea for sleep problems, and while it was helpful in a large number of patients, its side effects (including amnesia, rebound agitation, and short-term memory loss) were so dangerous it was actually removed from the market in England. Now the maker of the drug, Upjohn, has issued stringent guidelines and recommends that the drug not be prescribed routinely for periods greater than ten days. An urgent package insert with these new guidelines has been sent to every physician in the country.

Many physicians are not knowledgeable about sleep disorders, and they have very little time to counsel patients about this seemingly elusive and yet agonizing problem. In some cases the availability of powerful drugs can be deadly: a patient with a major depression may be prescribed a sleeping drug that accentuates the depression and triggers a suicide attempt.

Most hypnotics and sedatives change the nature of sleep. They alter REM cycles and shorten the amount of deep sleep. A person may be "sleeping" eight hours a night after taking a sedative without enjoying the refreshment of natural sleep. That may be one reason many sleeping-pill users complain of being hung over and drowsy the next day. After years of relying on these drugs, a person's health can be damaged in many subtle yet powerful ways.