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The Holistic Approach to Insomnia



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The Holistic Approach to Insomnia



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Jessica Peeling was a 4th year medical student from UNECOM in Biddeford, Maine on rotation at the Falcon Clinic in Utica, NY. She gave a presentation on "Insomnia" during a luncheon at the office.

Jessica Peeling was a 4th year medical student from UNECOM in Biddeford, Maine on rotation at the Falcon Clinic in Utica, NY. She gave a presentation on "Insomnia" during a luncheon at the office.

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The Holistic Approach to Insomnia

  2. 2. FIVE STAGES OF SLEEP Non-REM Sleep: Stage one- Light sleep, easily awakened, lasts up to seven minutes, production of alpha and theta waves Stage two- Also relatively light sleep, brain waves slow with occasional rapid firing called sleep spindles Stage three- Deep sleep, harder to rouse, body repairs muscles and tissues, boosts immune system, delta waves appear Stage four- Continuation of stage three, almost all delta waves and very deep sleep REM Sleep- First cycle happens approximately 90 minutes into sleep, lasts about 10 minutes, heart rate and respiratory rate increase, low voltage, high- frequency waves
  3. 3. DEFINING INSOMNIA • Insomnia - difficulty falling or staying asleep, or with early awakenings -generally occurring 3 or more times a week for at least one month -impairments reported in day-to-day life -occurs despite adequate opportunity and circumstances for sleep -subdivided into short-term, chronic, and “other” insomnia
  4. 4. SHORT-TERM AND CHRONIC INSOMNIA • Short-term insomnia is also referred to as adjustment, stress-related, transient or acute insomnia • Defined as occurring for less than three months • Usually related to an identifiable stressor • Resolves with relief of stressor • Chronic insomnia can be primary, secondary, or comorbid insomnia • Defined as occurring three times a week for three months or greater • Must not be related to inadequate opportunity to sleep or inappropriate sleep environment
  5. 5. INSOMNIA STATISTICS • Over five million office visits per year just in the United States • 69% of primary care patients in the US have insomnia at one point or another • 10% of individuals in the United States suffer from chronic insomnia • Higher prevalence in women • Correlation with poor socioeconomic status and marital issues • 3% of the population have insomnia with a comorbid psychiatric illness
  6. 6. INSOMNIA STATISTICS CONT • 37% of 20-39 year-olds report short sleep duration • 40% of 40-59 year-olds report short sleep duration • 35.3% adults report <7 hours of sleep during a typical 24-hour period • 3–5% of the overall proportion of obesity in adults could be attributable to short sleep • Costs the healthcare system $241 billion annually
  7. 7. SLEEP NECESSITY BY AGE Age Recommended duration of sleep Newborns (0-3 months) 14-17 hours Infants (4-11 months) 12-15 hours Toddlers (1-2 years) 11-14 hours Preschoolers (3-5 years) 10-13 hours School-aged children (6-13 years) 9-11 hours Teenagers (14-17 years) 8-10 hours Young adults (18-25 years) 7-9 hours Adults (26-64 years) 7-9 hours Older adults (>/= to 65 years) 7-8 hours
  8. 8. EFFECTS OF INSOMNIA • Decreased quality of life • Increased fatigue, sleepiness, confusion, depression, anxiety, and tension • Self-reported performance deficit • Increased risk of substance abuse • Hormonally-mediated increase in appetite, linked to increased BMI and obesity • Increased risk of diabetes (curvilinear relationship also) • Increased risk of fatal heart attacks • Increased age-specific mortality BMI vs Average nightly sleep
  9. 9. DIAGNOSIS • Studies have shown that health care providers are asking questions about sleep < 50% of the time • Psychiatric testing for comorbid disorders, Epworth sleepiness scale • Actigraphy • Polysomnography – when obstructive sleep apnea is part of your differential • Keeping a sleep log and sleep diary
  10. 10. STANDARD TREATMENT FOR INSOMNIA AND SIDE- EFFECT PROFILE • Benzodiazepines – Temazepam (Restoril), Flurazepam (Dalmane), Estazolam (ProSom), Triazolam (Halcion) • Nonbenzodiazepine hypnotics – Zolpidem (Ambien), Zaleplon (Sonata), Ezopiclone (Lunesta) • Melatonin agonists – Ramelteon • Antidepressants - Trazodone, Amitriptyline, Doxepin, Remeron • Suvorexant *** new, approved by FDA in 2014 but recently made available to prescribers • Atypical antipsychotics – Quetiapine (Seroquel), Olanzapine (Zyprexa) • OTC Sleep aids – Benadryl, Tylenol PM Most agents cause daytime sleepiness, fatigue, and dizziness Some cause complex sleep-related behaviors, anticholinergic effects, or problems with addiction and dependency
  13. 13. MELATONIN • A hormone that our body makes in the pineal gland • It is the end product of a biosynthetic pathway, starting with tryptophan • The suprachiasmatic nucleus in the hypothalamus controls melatonin production • Controls our circadian rhythm • Production naturally increases with decreasing light • Noctural secretion decreases with age • Most widely studied supplement for insomnia with the most scientific evidence • Very low doses of melatonin have been shown to be just as efficacious as higher doses -Normal physiologic production is only 2-200 pg/ml! Mean serum melatonin profiles of 20 subjects sampled at intervals after ingesting 0.1, 0.3, 1.0, and 10 mg of melatonin or placebo at 11:45 am
  14. 14. TRYPTOPHAN • L-tryptophan is an essential alpha amino acid present in concentrations of 1-2% in plant and animal proteins • It is converted to 5-HTP and then to Serotonin • Melatonin is made from tryptophan • It can penetrate the blood brain barrier and has sedative effects • Common dose is 2-5 g/day • Preliminary clinical research shows decreased sleep latency and improvement in total sleep time • Can exacerbate eosinophilia, kidney, or liver dysfunction
  15. 15. VALERIAN • Valeriana officinalis – a perennial herb that is native to Asia and Europe • Applicable portion is the root • Valerian root contains as many as 150 compounds, including valepotriates, volatile oils, and valerenic acid • May potentiate and inhibit GABA A receptors and Adenosine A receptors • Poorly absorbed with large first-pass metabolism • Common dose is 200-600 mg/day • Has many studies with a large number of participants showing efficacy with improvement of sleep • Meta-analysis of 1,093 patients taking Valerian for sleep studied in 2006, and 1,317 studied in 2011 • Same efficacy as benzos??
  16. 16. CHAMOMILE • Matricaria recutita – an herb that is native to Germany • Applicable portion is the flowerhead, which contains apigenin • Has sedative properties • Many potential hypotheses for mechanism of action • Common dose is 200-300 mg/day • Recent study showing efficacy in 2011, based on fatigue severity schedule • Animal studies show that small doses help with anxiety, large doses with insomnia • May have estrogenic effects and reduces creatinine output
  17. 17. LEMON BALM • Melissa officinalis – a perennial herb and member of the mint family native to Europe • Applicable potions are the leaf and the leaf oil • Contains citronellal, neral, and geranial monoterpenoid aldehydes; flavonoids (including luteolin) and polyphenol compounds • Has sedative effects • Often sold in combination with Valerian, studies have done on this combination • Very few studies on the efficacy of lemon balm alone • Common dose is 500-1000 mg/day • Interactions with sedatives and thyroid medications
  18. 18. KAVA • Piper methysticum – a perennial plant, native to Pacific islands • Has sedative properties • Many hypotheses for mechanism of action • Also studied as an anxiolytic • Rhizome, root, and stem are the active portions • Pharmacological activity has largely been attributed to kavalactones (also known as kavapyrones) • Common dose is 100-300 mg/day • Avoid with liver disease, Parkinson's disease, a history of medication-induced extrapyramidal effects, and chronic lung disease
  19. 19. OSTEOPATHIC CRANIAL MANIPULATION Cutler MJ, Holland BS, Stupski BA et al Cranial manipulation can alter sleep latency and sympathetic nerve activity in humans: a pilot study. -University of North Texas Health Science Center, Fort Worth, TX -20 volunteers, 12 males, 8 females ages 22-35 • Compression of the fourth ventricle (“a technique in which the lateral angles of the occipital squama are manually approximated, taking the cranium into sustained extension and obtaining a still point”) • Sleep latency was assessed using standard Multiple Sleep Latency Test protocol, directly recorded efferent muscle sympathetic nerve activity was recorded • Sleep latency and sympathetic activity were decreased with the CV4 technique, as compared to sham treatment and placebo Patients may exhibit decreased CRI, cranial dysfunction, increased sympathetic tone or sacral dysfunction on osteopathic structural examination
  20. 20. COGNITIVE BEHAVIORAL THERAPY • Psychoeducation about sleep hygiene • Sleep restriction therapy • Stimulus control instructions – full evaluation of sleep habits and environment • Encouragement to avoid planning until out of bed, keeping sleep logs • Identify and modify sleep-interfering thoughts through discussion of sleep diary • Relaxation training • Finally, relapse prevention • Over 70% of patients shown to have lasting benefit in insomnia through CBTi • New online programs also available for utilization in rural or underserved areas “Sleepio” and “SHUTi” • Books for CBTi to suggest to patients – “Say Goodnight to Insomnia”, “Quiet your Mind and Get to Sleep”
  21. 21. ACUPUNCTURE AND ACUPRESSURE • Commonly used in China to treat insomnia • Regulating yin and yang to reinforce health • Acupuncture Increases y-amino butyric acid • 2009 meta-analysis of 46 randomized trials of 3,811 men and women showed a statistically significant benefit in symptoms of insomnia with acupuncture • Research shows some benefit of Acupressure point pressure- therapy
  22. 22. EFFECTS OF AROMATHERAPY ON SLEEP • The linalool component of lavender inhibits sympathetic nervous system activity and heightens parasympathetic nervous system activity • Most recently a study looked at 60 coronary ICU patients -Inhalation of 2% lavender essential oil for 15 days -Measured with Pittsburgh Sleep Quality Index and Beck Anxiety Inventory • Santalol, in sandalwood, has been showing to improve total waking time and NREM sleep in animal studies
  24. 24. RESOURCES • Baddeley, J. L., PhD., & Gros, D. F., PhD. (2013). Cognitive behavioral therapy for insomnia as a preparatory treatment for exposure therapy for posttraumatic stress disorder. American Journal of Psychotherapy, 67(2), 203-14. • Effects of Inhalation Aromatherapy on Symptoms of Sleep Disturbance in the Elderly with Dementia • Rosick, ER. The Use of Supplements, Herbs, and Alternative Therapies in the Treatment of Insomnia. Osteopathic Family Physician (2014)2, 14-18 • Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem • • • National Sleep Foundation’s Sleep Time Duration Recommendations: Methodology and Results Summary • https://naturalmedicines-therapeuticresearch-com • Cutler MJ et al., Cranial manipulation can alter sleep latency and sympathetic nerve activity in humans: a pilot study. J Altern Complement Med. 2005 Feb;11(1):103-8 • • Up-to-Date: Treatment of insomnia in adults, Physiology and available preparations of melatonin, Clinical features and diagnosis of insomnia in adults • •

Editor's Notes

  • These stages progress in a cycle from stage 1 to REM sleep, then the cycle starts over again with stage 1. We spend almost 50 percent of our total sleep time in stage 2 sleep, about 20 percent in REM sleep, and the remaining 30 percent in the other stages. Infants, by contrast, spend about half of their sleep time in REM sleep.

    During stage 1, which is light sleep, we drift in and out of sleep and can be awakened easily. Our eyes move very slowly and muscle activity slows. People awakened from stage 1 sleep often remember fragmented visual images. Many also experience sudden muscle contractions called hypnic myoclonia or hypnic jerks, often preceded by a sensation of starting to fall. These sudden movements are similar to the “jump” we make when startled. Some people experience a sleep disorder known as PLMS where they experience recurring leg movements movements.

    When we enter stage 2 sleep, our eye movements stop and our brain waves (fluctuations of electrical activity that can be measured by electrodes) become slower, with occasional bursts of rapid waves called sleep spindles. Heart rate slows and temperature drops

    Stage 3 -This is the deep sleep stage. It's harder to rouse you during this stage, and if someone woke you up, you would feel disoriented for a few minutes.
    During the deep stages of NREM sleep, the body repairs and regrows tissues, builds bone and muscle, and strengthens the immune system.
    As you get older, you sleep more lightly and get less deep sleep. Aging is also linked to shorter time spans of sleep, although studies show you still need as much sleep as when you were younger

    In stage 3, extremely slow brain waves called delta wavesbegin to appear, interspersed with smaller, faster waves. By stage 4, the brain produces delta waves almost exclusively. It is very difficult to wake someone during stages 3 and 4, which together are called deep sleep. There is no eye movement or muscle activity. People awakened during deep sleep do not adjust immediately and often feel groggy and disoriented for several minutes after they wake up. Some children experience bedwetting, night terrors, or sleepwalking during deep sleep.

    REM sleep – rapid eye movement sleep, with low voltage high frequency waves, first cycle is 90 minutes into sleep, lasting about 10 minutes, but as the night goes on, the period of time spent I REM increases, usually up to about an hour. We breathe very shallow and have a more rapid heart beat during this time. This is also when we experience dreams.
    Babies can spend up to 50% of their sleep in the REM stage, compared to only about 20% for adults.
  • Insomnia is usually defined as the difficulty falling asleep or staying asleep, and also experiencing early awakenings, current criteria are listed here – impairment in day-to-day life, occurring despite having adequate opportunity and circumstances for sleep.

    The international classification of sleep disorders formally recognizes short term, chronic and other as categories of insomnia
  • Also referred to as adjustment, stress related, transient, or acute insomnia, occurring for less than three months
    Usually there is an identifiable stressor, such as grief, pain, financial or relationship difficulties, new environement, medication related
  • It is one of the most common complaints that we see in primary care offices – five million visits per year, just in the us alone
    A study was conducted showing 69% of primary care patients had insomnia, with 50 percent being short-term and 19 percent being chronic
    A review of 50 studies in 2002 showed that 10% of individuals in the United States suffer from chronic insomnia
    Higher prevalence in women
    Correlation with poor socioeconomic status and marital issues
    3% of the population have insomnia with a comorbid psychiatric illness
  • National sleep foundation recommends these hours for sleep by age, this was newly changed in February of 2015, based on a rigorous review of national studies
  • Patients with insomnia have decrements in both medical and emotional aspects of life, as determined by a standard measure of quality of life, the Medical Outcomes Study Short Form (SF-36) [14]. The magnitude of the impairment was similar to that seen in patients with a chronic medical condition (eg, heart failure) or depression.
    Quality of life can also be measured by looking at employment measures, such as promotions and sick time. Patients with insomnia are less likely to receive promotions and more likely to have errors or accidents, to be absent from work, and to have more health-related consequences [13,15]. The poor work performance, increased medical issues, and increased emotional burden associated with insomnia increase costs to society

     Patients with insomnia are almost universally concerned that their poor sleep has negative consequences on their performance of daily tasks and consistently report subjective performance deficits [18,19]. However, patients with insomnia tend to overestimate the magnitude of the performance deficit, just as they tend to overestimate the magnitude of their sleep deficits.
    Numerous studies have examined psychomotor performance in patients with insomnia compared to controls and the only consistent deficit found was a decrement in balance [13]. About 20 percent of measures involving memory were significantly decreased in some studies but not others

    28% have tried alcohol for self-medication

    Curvilinear relationship between BMI and average nightly sleep.

    Sleep insufficiency was associated with lower levels of leptin, a hormone produced by an adipose tissue hormone that suppresses appetite, and higher levels of ghrelin, a peptide that stimulates appetite, also contributes to OSA

    Five hours of sleep or less was associated with a 45 percent increase in risk (odds ratio [OR] = 1.45, 95% confidence interval [CI], 1.10–1.92), after adjusting for age, BMI, smoking, and snoring. Similarly elevated risks were also found for sleeping 9 hours or more.

    Sleep loss is also associated with increased age-specific mortality, according to three large, population-based, prospective studies (Kripke et al., 2002; Tamakoshi et al., 2004; Patel et al., 2004). The studies were of large cohorts, ranging from 83,000 to 1.1 million people.

  • The sleep history should elicit a detailed description of the sleep problem (ie, number of awakenings, duration of awakenings, duration of the problem) and sleep times (ie, bedtime, duration until sleep onset, final awakening time, nap times, and nap lengths) over both a 24-hour period and week. It also includes an assessment of any symptoms of disturbed sleep (eg, daytime sleepiness, fatigue), the duration of the symptoms (ie, acute or chronic), and the sleep environment

    Actigraphy uses either an activity monitor or a motion detector to record movement. The absence of movement for a continuous period of time is suggestive of sleep, while sustained movement for a continuous period of time is suggestive of wakefulness [44,45]. Actigraphy can be used to confirm sleep log data and to calculate sleep latency and sleep efficiency, if used in combination with sleep log data.

    Beck Depression Scale and the State-Trait Anxiety Inventory

    There is a printable form of this sleep log that you can use for compliant patients
    Sleep diary

    commercially available activity trackers, the reliability and validity of only one device (Fitbit Flex) has been tested against PSG and actigraphy.24 The study authors simultaneously recorded PSG, actigraphic, and Fitbit data from a single laboratory-based overnight recording in 24 healthy adults (age range: 19–41 y). They showed that both Fitbit and actigraphs had a high sensitivity. Also, similar to actigraphy, Fitbit overestimated sleep efficiency (mean ± standard deviation [SD]: 14.5 ± 10.7 %) and total sleep time (mean ± SD: 67.1 ± 51.3 min) with poorest agreement against PSG in individuals with lower sleep efficiencies and sleep time. These results suggest that Fitbit may be an acceptable sleep tracker device for use in healthy adults

    Epworth Sleepiness Scale is an example of a validated questionnaire that can be used to assess daytime sleepiness. It asks questions about the chances of dozing off during various daily functions such as watching TV, sitting and reading, or driving a car.

  • Benzos - sleep promoting medications that bind to several gamma-aminobutyric acid (GABA) type A receptor non benzos – one specific type of gaba a receptor

    Ramelteon promotes the onset of sleep by increasing levels of the natural hormone melatonin, which helps normalize normal circadian rhythm and sleep/wake cycles. Ramelteon is approved by the U.S. Food and Drug Administration (FDA) for insomnia characterized by difficulty falling asleep. These drugs have a relatively mild side effect profile, a lower likelihood of causing morning sedation, and may lack the potential for abuse and dependence. The body regulates back to normal daytime levels of melatonin when it is daylight. Side-effects may include daytime sleepiness, dizziness, and fatigue.

    Suvorexant blocks the binding of wake-promoting neuropeptides orexin A and orexin B to receptors OX1R and OX2R, which is thought to suppress wake drive.

    Anticholinergic effects from otc sleep aids - dry mouth, blurred vision, urinary retention, constipation, and increased intraocular pressure

    The most common adverse effects associated with the benzodiazepines and nonbenzodiazepines are residual daytime sedation, drowsiness, dizziness, lightheadedness, cognitive impairment, motor incoordination, and dependence [1,60,61,66]. In addition, most hypnotics are respiratory suppressants that can worsen obstructive sleep apnea or hypoventilation.
    Long-term use may be habit forming and rebound insomnia may occur when some short-acting medications are discontinued. Less common adverse effects include complex sleep-related behaviors (eg, sleep walking, driving, making telephone calls, eating, or having sex while not fully awake), anterograde amnesia (particularly with triazolam or when used with alcohol), aggressive behavior, and severe allergic reaction

    Most BZDs are only recommended for treating short-term (2-4 weeks) insomnia because they can disrupt sleep architecture
  • Sleep hygiene is the promotion of healthy, regular sleep

    National Sleep Foundation recommendations:
    Go to bed at the same time each night and rise at the same time each morning.
    Make sure your bedroom is a quiet, dark, and relaxing environment, which is neither too hot or too cold.
    Remove all TVs, computers, and other "gadgets" from the bedroom. – try not to use cellphones, ipads, or kindles for a long time before bed, and place them face down so light is emitted
    Make sure your bed is comfortable and use it only for sleeping and not for other activities, such as reading, watching TV, or listening to music. Avoid large meals before bedtime

    Avoid naps! They increase sleep debt, which is the cumulative effect (which is kind of controversial) of someone not having sufficient sleep – researchers are unsure if this is yet a measurable phenomenon
    If you’re awake for more than 10-15 minutes in bed, get up and do something
    Avoid caffeine after lunch and alcohol close to bed
    Warm bath or meditation before bed
    White noise sound machines
  • Not FDA approved, but the most common supplements noted in multiple journal articles and research studies. Still have potential for side-effects, but the instances are fewer and less severe than with standard medications. As with all medications, there can be interactions – especially with some of the medications you might be prescribing for insomnia, so its important to check and do your research before suggesting a supplement to a patient. Best scientific evidence is for melatonin, ill briefly go over each of these supplements.
  • A randomized, double-blind placebocontrolled trial of 2 mg prolonged release melatonin was done in 2010 on 791 men and women, aged 18-80 years, with primary insomnia.14 Over an eight-month period, the authors showed that elderly patients receiving melatonin had a statistically significant decrease in their sleep latency, which was maintained over the treatment period.

    Both have been shown to be produced by physiologic doses (ie, 0.1 to 0.3 mg for sleep and 0.3 to 0.5 mg for phase shifting, doses which raise daytime plasma melatonin levels into the normal nocturnal range observed in young adults). We therefore suggest the use of lower, more physiologic doses of melatonin, particularly in older adults (figure 3) [72]. When preparations providing 0.3 to 0.5 mg are unavailable, the user can purchase 1.0 mg pills and cut them in half.
    Although melatonin is relatively nontoxic, some marketed doses (1 to 10 mg) can elevate plasma concentrations to 3 to 60 times their normal peak values (figure 3) [54]. Supraphysiologic concentrations of melatonin produce numerous biological effects, including daytime sleepiness, impaired mental and physical performance [73], hypothermia [26], and hyperprolactinemia [74]. These effects are not observed with physiologic concentrations of melatonin
  • A small, double-blind placebocontrolled trial examined the effects of 2 grams of tryptophan administration in eight middle-aged men and women.17 Patients taking tryptophan showed a decrease in their sleep latency with no undesirable side effects. Another similar study examined the effects of the supplementation of 5 grams of tryptophan on patients with insomnia.
  • Finally, a recently published article (2011) reported on the effects of valerian on sleep quality in postmenopausal women.27 In this randomized, placebo-controlled triple-blind trial of 100 women aged 50-60, subjects took either 530 mg of valerian extract or placebo twice a day for four weeks. The results of the study showed that the women taking valerian had a statistically significant improvement in their quality of sleep

    Two meta-analysis of randomized placebo-controlled trials of valerian for sleep (one done in 2006 in the United States and one in 2010 in Europe) showed that valerian was effective for the treatment of insomnia.26,27 The 2006 report identified 16 studies with a total of 1,093 male and female patients. The authors reported that random effects modeling of the pooled data showed that the use of valerian almost doubled the chances of sleeping better when compared with placebo. The 2010 European study analyzed 18 studies with a total of 1,317 male and female patients and concluded that, “The qualitative dichotomous results suggest that valerian would be effective for a subjective improvement of insomnia, although its effectiveness has not been demonstrated with quantitative or objective measurements

    Other, newer studies have confirmed the efficacy of valerian in treating insomnia. A randomized, double-blind study published in 2002 compared the effects of 600 mg valerian root extract versus 10 mg of oxazepam among 202 male and female patients, aged 18-73, who suffered from insomnia.28 At the end of this six-week study, both valerian and oxazepam reduced time to sleep and increased sleep length. In addition, according to multiple subscales (refreshment after sleep, exhaustion in the evening, dream recall, and duration of sleep), both agents showed essentially the same efficacy
  • The constituent(s) responsible for the sedative activity of German chamomile are unclear. Some preliminary research suggests that apigenin can bind to gamma-aminobutyric acid (GABA) receptors. GABA receptors are the primary receptor sites of benzodiazepines in the central nervous system. However, other research suggests that apigenin doesn't affect GABA receptors, and other constituents of German chamomile are responsible for the sedative activity

    A recent study published in 2011 examined the effects and efficacy of chamomile extract for insomnia.31 In this randomized, placebo-controlled double-blind study, 34 men and women, aged 18-65 years, with the diagnosis of insomnia were randomized over a 28-day period to receive either placebo or 270 mg of chamomile extract daily. Those patients randomized to the chamomile group showed a small to moderate decrease in sleep latency, nighttime awakenings and Fatigue Severity Schedule, leading the authors of the study to conclude, “Chamomile could provide benefits of daytime functioning and mixed benefits on sleep diary measures relative to placebo in adults with chronic primary insomnia.”
  • In another double-blind, placebo-controlled study, 18 healthy volunteers received 2 separate single doses of a standardized lemon balm extract (300 mg and 600 mg) or placebo for 7 days. The 600 mg dose of lemon balm increased mood and significantly increased calmness and alertness.

    In this prospective, open-label study, 20 men and women, aged 18-70 years, took 600 mg of a proprietary lemon-balm extract twice daily for 15 days. At the end of the study, 14 out of the 20 patients reported full remission of their anxiety, while 85% (17/20) reported resolution of their insomnia.
  • Recent study showed that 200 mg of standardized kava extract (WS 1490) taken for four weeks caused a self-reported increase in quality of sleep – 61 men and women

    MOA - Kava is known to have sedative properties, and it is hypothesized that this is brought about by GABA-binding activities of some of the plants biochemically active constituents.3
  • Stimulus control[4] aims to associate the bed with sleeping and limit its association with stimulating behavior. People with insomnia are guided to do the following:
    go to bed only when they are tired
    limit activities in bed to sleep and sex
    get out of bed at the same time every morning
    get up and move to another room when sleep-onset does not occur within ten minutes

    Sleep restriction[5] is probably the most controversial step of CBT-I, since it initially involves the restriction of sleep. Insomniacs typically spend a long time in bed not sleeping, which CBT-I sees as creating a mental association between the bed and insomnia. The bed therefore becomes a site of nightly frustration where it is difficult to relax. Although it is counterintuitive, sleep restriction is a significant and effective component of CBT-I. It involves controlling time in bed (TIB) based upon the person's sleep efficiency in order to restore the homeostatic drive to sleep and thereby re-enforce the "bed-sleep connection".[6] Sleep Efficiency (SE) is the measure of reported Total Sleep Time (TST), the actual amount of time the patient is usually able to sleep, compared with his or her TIB.
    Sleep Efficiency = (Total Sleep Time / Time In Bed)
    First, Time In Bed is restricted to the Total Sleep Time
    Increase or decrease TIB weekly by only 20-30 min
    Increase TIB if SE >90%
    Decrease TIB if SE <80%
    This process may take several weeks or months to complete

    Hypnosis, guided imagery, meditation
    Patients who have undergone CBT-I spend more time in stages 3 and 4 sleep – more than those with hypnotics
  • One study revealed that acupuncture was more efficacious than benzodiazepines and acupuncture together

    The Acupressure Points (K 6 and B 62) between your heel and anklebones (on both sides) have traditionally been used to relieve and prevent insomnia. The acupressure point on the inside of the heel below your inner anklebone is called Joyful Sleep

    The Acupressure points on the outside of your heel, below your outer anklebone are called Calm Sleep. Pressing these ankle points together by placing your thumb on one side and your fingertips on the other side of your ankle, can relieve pain from the waist down, and enable your body to relax deeply for a good night’s sleep.
  • lavender aroma and the linalool component inhibit sympathetic nervous system activity and heighten parasympathetic nervous system activity.

    Another study on elderly patients with dementia and insomnia was conducted last month
  • Walnuts cause your brain to secrete melatonin
    Almonds contain tryptophan and magnesium, which naturally relaxes your muscles to stimulate rest
    Lettuce – contains lactucarium with sedative properties
    Tuna – Vitamin B6 which helps in the productin of melatonin
    Cherries – Melatonin and tryptophan, studied showed cherry drinkers get 84 minutes of sleep on average
    Banana – B6
    Whole grains – rich in magnesium
    Honey – fructose and glucose that help your liver produce glycogen, because if your body doesn’t have enough glycogen, you may wake up at night
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