A Holistic Approach to Insomnia

Q:  I’m generally exhausted by the end of the day so I fall asleep just fine, but I wake up at 3 or 4 every night and can’t go back to sleep. Do I have insomnia or is something else going on?

A:  Yes, you do have insomnia, but not the movie-scene tossing-and-turning-for-hours-before-you-fall-asleep variety. Science defines insomnia as repeated difficulty with the initiation, duration, maintenance, or quality of sleep that occurs despite adequate time and opportunity for sleep and results in some form of daytime impairment. So your wee-hour wake-ups certainly qualify as insomnia—they’re just a different type. Sleep specialists classify what you’re experiencing as a “sleep maintenance” problem. They consider not being able to fall asleep when you first hit the sack a problem with “sleep latency.” While both types of insomnia can share many of the same causes—too much stimulation before going to bed (from food, drink, or TV), job- or life-related stress or worry, a chaotic or irregular sleep routine—sleep maintenance problems can also stem from a couple of biochemical issues.

The first concerns melatonin, a hormone secreted by the pineal gland in the evening once the sun has set. According to the National Sleep Foundation, melatonin levels normally start rising about 9 p.m. in response to darkness and stay elevated until dawn, when daylight triggers the brain to turn off the flow. If we’re not exposed to bright light during the day or to darkness in the evening (especially in the bedroom), our melatonin levels may stay low, and even though our exhausted body surrenders to sleep initially, an agitated mind can wake it up before it’s completely rested.

Unfortunately, our crazy electronic, lit-up world can convince our brains that it’s always daytime. To counteract that, you may need to invite the night in by turning down the lights and unplugging your gadgets for a bit before going to bed. Or go out for a nighttime stroll—the exercise can also help calm the mind and body. If these suggestions—coupled with a good sleep hygiene program that includes a nightly wind-down routine, avoidance of stimulants, and a regular sleep/wake cycle—don’t do the trick, you can try melatonin supplements. Take 1 to 3 mg about 30 minutes before bedtime for up to two weeks and then increase to 5 to 10 mg, if necessary. I don’t recommend melatonin supplements as a long-term daily treatment, but they’re excellent for short-term (or periodic) sleep support.

Cortisol also rises when we’re under stress (it’s part of the body’s fight-or- flight response), so in many individuals with high-stress jobs or lives, the level of this wake-up chemical stays elevated all the time—even when they’re asleep.

A second cause of sleep maintenance problems involves what’s often called the anti-sleep hormone. When the brain turns the melatonin spigot off for the night, it signals the body to produce another chemical, cortisol, to jump-start our morning. Cortisol levels increase 50 to 160 percent within 30 minutes of first waking up and then gradually fall throughout the day, hitting their lowest levels between 11 p.m. and midnight. Cortisol also rises when we’re under stress (it’s part of the body’s fight-or- flight response), so in many individuals with high-stress jobs or lives, the level of this wake-up chemical stays elevated all the time—even when they’re asleep. Again, although they may fall asleep normally, as soon as the body gets a few hours rest, the cortisol wakes them up.

You can lower your cortisol level throughout the day by finding ways to counteract the stress of work and everyday life. Yoga and meditation can play important roles here, as can aerobic exercise, sanity breaks, pranayama, prayer—anything that will allow the mind and body to relax. But if unremitting stress over a long period of time has thrown the cyclical rise and fall of cortisol seriously out of whack—so that its morning wake-up call occurs at 4 a.m., say—then you’ll need to reset things. Adaptogenic herbs like ginseng, cordyceps, rhodiola, astragalus, and licorice root help our bodies counter stress by nourishing the adrenals and supporting homeostasis. They boost the immune function as well, without creating unwanted side effects. You can try an over-the-counter ginseng or cordyceps formula, but if they don’t work, a naturopath, an herbalist, a doctor of Chinese Medicine, or an ayurvedic practitioner can better determine your body’s needs and how to address them.

Yoga and meditation can play important roles here, as can aerobic exercise, sanity breaks, pranayama, prayer—anything that will allow the mind and body to relax.

And finally, studies have long claimed that sleep maintenance insomnia is a hallmark symptom of depression, although more recent studies suggest that it may be a cause as well—and may in fact signal the near onset or relapse of the condition. The two aren’t inexorably linked, of course, but if other remedies fail, you might look to your overall mental health. Interestingly, cognitive behavioral therapy (CBT), now a standard treatment for chronic insomnia, also seems to relieve depression. CBT uses psychotherapy and may include journaling and biofeedback to help a patient identify thoughts and behaviors that cause distress and then substitute healthy thoughts and actions in their stead.

But what about a short-term fix to get back to sleep once awakened? If counting sheep or using breath-related relaxation techniques fail to induce sleep within 15 to 20 minutes, most experts suggest you get out of bed and do something relaxing in another room—like your wind-down routine or listening to calming music—and go back to bed only when you feel drowsy.