Posted tagged ‘Insomnia’

Why an integrated approach?

January 26, 2010

There are a vast number of ways to approach sleeping problems.  Some are, in my opinion, utterly worthless.  I am not interested in purported treatments which are based on sham theories or have failed to stand up to scientific testing.  There are, however, a number of treatments which at present hover uncertainly between the alternative and orthodox worlds of medicine.

Light therapy is mostly on the orthodox side, for instance, although I have heard of a few rather dubious applications of it, such as a pulsed light mask that purports to treat migraine and PMS (there was one trial by the manufacturer, then it was never heard of again).  Bright light therapy for Seasonal Affective Disorder is by now very well established and offered as a routine treatment in many countries.  A smaller but still significant number of trials have shown that it is almost as effective for non-seasonal depression.  Bright light therapy for sleep disorders has been fairly well researched by now, but it is not yet as well established within the medical profession, although I think it is slowly getting there. Dawn simulation has generally been researched for SAD (it mostly comes out as nearly as effective as bright light therapy) and for sleep, in particular for people who struggle to get up in the morning.

Darkness therapy is a much smaller affair, perhaps because there is less money to be made by selling products for it.  It is generally researched by the same people who research light therapy and follows on from the same research, for instance into how different wavelengths of light are received by the eye and affect hormones within the body.  The main application at present is sleep, although there has been some interesting research concerning rapid cycling bipolar disorder.

Herbalism is a big sprawling system of medicine that has been going on for thousands of years and probably contains every plant known to mankind by now.  Various orthodox medications are based on herbal remedies, for instance aspirin comes from willow bark, and some of the most effective have become relatively well integrated into orthodox medicine in some countries.  Since a few herbs have been subject to a decent number of clinical trials and have stood up well in research, I am sticking to those.  Herbal medicines are generally, though not always, milder in action than orthodox medicines and with a lower rate of side-effects.  Sadly, they are still poorly regulated and it is important to read up on dosage and make sure that you are buying from a reputable manufacturer.

Then there are the therapies where research is rather scanty but not entirely absent, and where at least some of the effect may come from the therapy’s being pleasant and relaxing.  I don’t think that aromatherapy will cure a severe sleep disorder, but I’ve heard many doctors recommend lavender oil for mild insomnia, and having a nice warm bath with Epsom salts (magnesium sulphate) seems to be at a similar level.

Advertisements

Darkness therapy

January 26, 2010

The idea behind this is that humans do best when they have melatonin being produced for half the time (averaged out over a year, it won’t be 12 hours all the time unless you’re living on the equator), and that it’s useful both for aiding sleep and for other things such as fertility and cancer risk.  I’m a little warier of claims that a yellow light bulb will fight cancer/get you pregnant than I am of the claims that it will improve sleep, so I’d treat that side of things as rather more speculative, but there does seem to be a fair amount of research backing it all up, if indirectly.  While darkness therapy itself may be fairly new, the various roles of melatonin have been studied a great deal by now.    There have been studies using 12 hours of complete darkness to treat bipolar disorder, but this is difficult to implement and is generally thought not to be necessary, though I’ve read a website by one guy who feels that it is essential and discusses washing up in the dark!  So while there appears to be a great deal of research on melatonin and sleep in general, for instance how shift work affects breast cancer risk, or on populations who do not have artificial lighting (and have many other major difference from industrialised countries), there is as yet little where researchers have directly studied darkness therapy by taking a group of people and changing nothing except the amount of darkness they get at night.  Hopefully this will be remedied before too long, although since there’s nothing in it for pharmaceutical companies, it may take a while.  All the research that I do know of can be found at LowBlueLights.com.

Since it’s blue light which affects circadian rhythms and tells the body that it should be awake and not producing melatonin, you can practise darkness therapy by simply omitting or filtering out blue light for several hours before you go to bed and while you are in bed.  There are a few ways of doing this, but the crucial thing is that once you have begun the darkness therapy in the evening, you do not get any white or blue light until the next morning, not even the tiniest bit.

Coloured light bulbs. For general use while awake, I prefer yellow-coated incandescent bulbs.  If you’re in the UK, they’re just sold as yellow bulbs.  If you’re in the US, they’re more likely to be called bug lights.  The bulb should be painted completely yellow, with a solid coating rather than a translucent one, and will produce an amber light which I find pleasant but which my partner, who generally dislikes coloured light, can’t stand. You can also get amber, red, or pink-coated bulbs, which you may prefer.  I’m not entirely sure whether the pink ones will filter out all blue light when used in an ordinary lamp, as I’ve only ever tried a 15W one inside a salt lamp, where the thick salt already filters out most of the blue.

Unless you live alone or are only planning to use these lights while alone (e.g. while breastfeeding or if you need to get up in the night because you can’t sleep), this is a potential snag.  As the coating is substantial, it will reduce the overall light output so that a 60W yellow bulb may be only as bright as a 40W white bulb, or even dimmer than that. You can buy fluorescent versions of these yellow-painted lights as well.  I haven’t tried them yet as I respond so badly to all fluorescent light, but I’m curious about how the yellow coating changes the level of visual comfort by filtering out certain bandwidths.  I tried buying an LED bulb that was sold to me as yellow, but it turned out to be a really nasty street-light orange; same goes for the two types of LED tea lights that I’ve tried.  I’ve been told by several lighting merchants that oranges and yellows are problematic for LEDs, it’s hard to get a pleasant colour.  I haven’t tried yellow halogen bulbs, but from the photos the yellow coating doesn’t look  strong enough to block all blue light.

For use when I’m going to the toilet at night, I bought a couple of red bike lights.  Since I’m an evening bather, showering was a problem.  I originally tried a red bike light, but while I can cope relatively well in near-darkness, it just wasn’t safe.  After puzzling over this for some time, I put a couple of lamps with 60W yellow bulbs on the hall, so that when the bathroom door is open, there’s a decent amount of light.

Even with coloured light bulbs, it’s best to keep the lighting in the evening fairly low.  At one point I had a 60w yellow bulb in a desk light by the bed for reading by, and a 25w bulb hidden behind a vase in the corner on my partner’s side of the bed for ambient background lighting.  Once I got the orange glasses, I eventually stopped using those, though I did acquire a salt lamp for ambient lighting which provides a nice orange glow.   (As far as I can tell,  the salt lamp filters out most blue light but not all, so you may need to get a coloured bulb for it if you’re going to be using it without tinted glasses on.)  If you do get tinted glasses, I’d recommend keeping on one lamp with a yellow bulb by the bed, for the occasions when you need a bit of light during the  night and don’t want to put your  glasses on.  There are various forms of gentle ambient lighting which are naturally low in blue light, such as candles or fairy lights, and for some people these will be an acceptable compromise.  If you go for fairy lights and you’re not going to be using tinted glasses, go for rice lights, which are a warm white, instead of LED lights, which are a cold light containing a lot of blue.  Unfortunately, I’ve found that even the small amount of light from fairy lights can be enough to halt melatonin production and keep me awake for hours if I don’t have my orange glasses on.  I may try “golden” LED fairy lights some time, but since all of the LEDs I’ve bought as yellow turned out to be a nasty orange, at the moment I’m using the salt lamp for my one yellow lamp.

Monitor filters. Computers and television screens emit an awful lot of blue light, and using them in the evening can really mess up your sleep all on its own.  Low Blue Lights and its friends sell expensive amber filters, but I simply got some samples of amber gels from a theatrical lighting company and cut them to size.  They stick on fairly well by static, unless you have the computer screen tilted quite far forward, and are easy to take off for daytime use.  I have a 17″ widescreen laptop and there are several inches to spare, so these would probably do you for up to 19″ or 20″ widescreen.  They’re a bit of a nuisance, they won’t work for larger monitors, and again my partner doesn’t like looking at them (some people just don’t get on with coloured light), but they’re cheap.  Brown filters should theoretically do the same job with minimal colour distortion if you can’t stand orange, though they will need to be fairly dark.

If you’re looking at a monitor through an amber filter or glasses, colours will be quite strongly affected.  The general effect is golden yellow more than orange, oddly enough.  Whites will be yellow, blues will be greens, everything will be a bit different.  This may annoy you, and it may restrict your activities.  I can’t do any quilting that requires me to select colours, and it’s not the time to go internet shopping for clothes.  This isn’t entirely a bad thing, as it forces me to wind down in the evenings and look at those hours during darkness therapy as relaxation time.

Tinted glasses.  There are two ways of doing this.  You can buy ready-made tinted glasses which will block all blue light, for instance from the range at Optima Low Vision, or you can get prescription glasses made up with a tint that will block blue light.  If you want to try standard sunglasses in brown, orange, yellow or red, check with an optician to find out whether they block 100% of blue light, as apparently most of them don’t.  You also want these glasses to provide good coverage, as opposed to some of the tiny lenses you can get these days.

If you’re going for anything expensive, try out darkness therapy with coloured bulbs and optionally monitor filters first to see whether you get on with it and whether it helps.  Since I can’t see without glasses, I decided to try some fitover glasses in amber which had the advantage of very good coverage.

Unfortunately I found them horribly uncomfortable, and they looked terrifying on me, being huge and so dark (much darker than the image shows) that my eyes were utterly obscured, along with half my face.  My partner and I didn’t want our evenings together spoilt by this, so I gave up on the fitover school of thought and had some prescription glasses made up instead.

On my optometrist’s advice, they were tinted with Wratten Tint 21, which is a pleasant orange.  Optical Express (who do some rather nice cheap frames) don’t do that tint as standard, but they could get that orange in 50% light transmission, which was more than enough to block 100% of blue light but still not so dark that my eyes were obscured to someone looking at me.  They called it 500 Orange 50%, and it cost the same as an ordinary tint. (Remember that brown is just orange with black added, so while they will look more conventional and may distort colours less, brown-tinted glasses will need to be darker.)  The glasses are rather fetching, if I say so myself, and I’ve had no complaints that they make me odd to be around.

I still keep the ambient lighting low when possible, as there will be a bit of light creeping in around the edges, and sometimes I put on the salt lamp so that the light is a soft orange.  However, I’ve spent enough time wearing these glasses with ordinary indoor lighting to confirm that they work beautifully in any conditions, and you don’t need to worry too much about what your light bulbs are up to.

I generally put on the glasses at about 9.30 for a bedtime of midnight, and have been using them for four months.  I’m getting sleepy earlier in the evening, sometimes I even fall asleep at 11ish, and I’m sleeping more solidly.  I’d estimate the effect of the darkness therapy to be similar to that of taking a sleeping tablet in terms of getting a good night’s sleep, but without the potential side effects or grogginess the next day.  I find the glasses very relaxing to wear.  If my partner comes home late in the evening, in the past I’d be so thoroughly woken up that I couldn’t get back to sleep for hours.  Now he’s lucky to get a coherent “hello darling” out of me, and I go straight back to sleep.  I haven’t had an episode of not being able to sleep until unholy o’clock in the morning, or waking up at night and not being able to get back to sleep for well over an hour, since I started using the glasses. There have been a few nights where I’ve forced myself to stay up until 2, yawning all the time, but where in the past (using bright light therapy alone) I would have messed up my sleep cycle by doing that and would be unable to sleep before 2 (or worse) for the nights afterwards, now (using bright light therapy, dawn simulation and darkness therapy) my sleep pattern snaps right back into place.  The only exception to this is the one night where I made the mistake of having the fairy lights on for half an hour around midnight when my orange glasses were off, as I’d hoped that they were yellowy and dim enough not to disrupt melatonin production.  The ensuing insomnia made me realise just how dreadful my sleep was in the old days, and how enormously it’s improved since then.

Sleep hygiene

January 26, 2010

Google this and read a few articles on it.  This one by the ME specialist and researcher Dr Sarah Myhill* is particularly useful, though I’m not convinced that we should all be going to bed at half-past nine (Dr Myhill does admit that she’s a natural “lark” herself).  Note the areas you’re not doing well in and think about how you might be able to improve them, even if it’s just partially.  The main thing I had to stop doing was staying on the internet too late, it’s a big sleep-killer.  It’s important to keep yourself in a steady routine as far as possible, including regular mealtimes, if you have any problems with circadian rhythms.

For those of you who aren’t in the mood for hunting around for different articles, here are some sleep hygiene tips.

  • Your bed should be blissfully comfortable.  Opinions on exactly what your bed should be like seem to vary, so read up on this if you’re in any doubt, but you probably know what you prefer.  Do remember not to let your mattress get too elderly.
  • Reserve your bed for sleep and sex, so that your brain doesn’t associate it with wakefulness.  If there are good reasons why that’s not possible, for instance due to having ME/CFIDS, do think about how the process of association works and consider workarounds, such as switching to the sofa for part of the day, or even a spare bed.
  • Generally think about relaxing pre-bedtime routines and how you think about sleep.  Routines can make a surprising difference, and it helps to have a daytime mindset and a bedtime mindset.
  • Meditation, visualisation and the like can be very helpful, especially if your mind goes whizzing round in the evenings.  There are lots of different ways you can do this, so keep looking if the first method you find merely irritates you.  I quite like a Zen meditation technique where you repeatedly count to ten, one number with each breath.  Usually I just drift off while daydreaming.
  • It’s well-known that caffeine will keep you awake, but few people know that alcohol and nicotine do as as well.  If this applies, you can either change your habits in a big way, or at least remember not to drink/smoke after lunchtime for special occasions, such as when you will have to be up for an early morning appointment or anticipate that something will disrupt your sleep (e.g. travelling on an overnight bus).
  • Try to reserve energising activities for earlier in the day.  This can be tricky for natural night owls who feel at their most creative in the evening, or people who only really come to a few hours after they finish work, but it’s worth thinking about if you want to improve your sleep.  Knowing your natural tendencies is a big part of the battle.
  • Strenuous exercise is best reserved for earlier in the day, say up to mid-afternoon.
  • Computers are lethal for keeping you awake in the evening.  This is partly because they engage your mind, and partly because they emit a lot of blue light which suppresses the sleep hormone, melatonin (keep reading to find out more about this).  Either stay off the computer altogether, or use an orange screen filter, preferably combined with keeping to less energising activities (playing computer solitaire is fine, writing a blog post about something that really excites you is likely to lead to “how did it get to 5 am?” syndrome).
  • Televisions pose similar problems to computer screens, both in terms of blue light and getting your brain involved.  I manage as long as I wear my orange glasses to block the blue light, and generally keep to something relatively soporific if it’s just before bed.  This is the time for watching an episode of a not-terribly-exciting TV series, not for starting a two hour horror film.
  • Know your bladder!  Some people find that they go to the toilet all night if they so much sip a little water in the evening, in which case set yourself a time after which you won’t drink anything, or at least restrict fluids.  Other people are fine whatever they do, and these folks are good candidates for calming herbal teas, such as chamomile or lemon balm (melissa).  I recommend Dr Stuart’s Valerian Plus, which has a goodly amount of valerian in it, along with passiflora and hops which are both useful for sleep, but it doesn’t taste too bad for a valerian tea, probably because it has lots of linden blossom (lime flowers), which tastes beautiful as well as being calming.  If you find chamomile effective but don’t like the taste, there are some good chamomile blends out there, such as Twinings Chamomile & Limeflower.
  • Warm baths help for some people.  You can add Epsom salts (magnesium sulphate), which are meant to relax the muscles, or a few drops of a calming essential oil such as lavender.  If you go for the aromatherapy option, don’t get too hung up on which oils are prescribed for insomnia, as reaction to smell is intensely personal and you just want whatever makes you feel relaxed.  Check whether the oil is listed as sedating (neroli is wonderful, although pricey so buy it diluted for this) or stimulating (rosemary is definitely not a bedtime oil).
  • You can also utilise aromatherapy by putting a single drop of a calming oil on a tissue and keeping it near your pillow.  I don’t recommend oil burners which use candles for obvious safety reasons; if you want to use an electric oil burner, plug it into a timer so that it won’t be on all night.  Another pleasant use for aromatherapy is to buy or make up an oil blend with calming essential oils, such as Roman chamomile and bergamot, and either apply it to yourself or, better still, get your partner (if you have one) to give you a gentle massage.
  • Some people are kept awake by chilly feet.  If this is the case, there’s the obvious sock option and the marginally less obvious hot water bottle or microwaveable rice bag option.
  • Warm bed, cool room, seems to be the advice I’m finding on most sites.  Probably worth following, and fresh air is always good, but as ever, go for what makes you most comfortable, don’t follow something you don’t get on with just because a website suggested it.
  • If you’re kept awake by worries or other thoughts, and you are either single or have a very deep-sleeping partner, you can try keeping a notepad by the bed for writing down anything that is keeping your mind on the hamster wheel.  Use a dim light for doing this, preferably one that is yellow, orange or red (see the articles on darkness therapy).
  • If you can’t get to sleep, or wake up in the night and can’t get to sleep, give it 20 minutes (this is the usual recommendations; many people would consider 20 minutes fantastically fast to get to sleep, so it may need to be longer for you), and if you still can’t sleep, go and do something relaxing in another room, such as reading or listening to soft music.  Again, use yellow/orange/red light if possible, and dim light at the very least.
  • And this applies for getting up to use the toilet in the night too.  It only takes a short exposure to white/blue light to suppress melatonin levels, unfortunately.  Don’t forget to take the hallway light levels into consideration either.
  • If your child insists on a nightlight, or you need one for navigating hallways, find something that’s yellow/orange/amber/red.  It is ludicrous how many nightlights are just the right kind of bluish white that will keep you awake.
  • On that subject, speak to your doctor if you’re being kept awake by your urinary tract or digestive system.  It is not normal to need to urinate several times during the night, or to be kept awake by gas, and it may be a sign of Overactive Bladder Syndrome, Irritable Bowel Syndrome or a food intolerance (e.g. gluten), amongst other possibilities.
  • Ditto for pain: I don’t care if you dislike painkillers, any pain that is disrupting your sleep is serious enough to warrant being discussed with a doctor.  You may need to take medication or alter the medication you’re taking already, and you may also be able to find a non-drug solution.  Remember that poor sleep increases daytime pain levels, so it’s a vicious circle very much worth breaking.
  • While I’m marching people off to their doctors, remember that how you sleep reflects your mental health as well.  If you’re up half the night every night worrying, you may have an anxiety disorder, for instance.  Just because you may been experiencing it for as long as you can remember doesn’t mean that it’s healthy!
  • Find out what sort of sleep is normal for your age group, rather than following myths.  It is perfectly normal for teenagers to be on a late schedule, though this should improve by 20 or so.  It is not the case that you need less sleep when you’re elderly, however, although many elderly people do sleep less due to, say, pain from arthritis, or other similar problems which – you’ve guessed it – should be discussed with a doctor.
  • If an external factor is disrupting your sleep, don’t just assume that everyone has to put up with this, as there may be a solution for it.  Darkness therapy is useful for shift workers and new parents, for instance.  New curtains, if yours are letting the light in, may be unaffordable, but clip-in blackout linings are cheap and very effective.
  • If your partner snores, consider the following: earplugs, a white noise generator/tinnitus relaxer (some can be plugged into a pillow), separate bedrooms.  If you haven’t done this already, march them off to the doctor to be checked for sleep apnoea, a very common and rather dangerous condition.  This may mean that you end up having to listen to their CPAP machine instead of their snores, but at least they’ll be a lot healthier.

* Please note that Dr Myhill is now being viewed with caution.  See the Links page for more information.

    Get a diagnosis

    January 26, 2010

    Work out what’s wrong with your sleep, and if necessary, see a doctor or even a sleep clinic.  Some sleep problems such as sleep apnoea are actually quite dangerous and warrant early investigation.  Note that in the UK at least, sleep clinic waiting lists are long, and if you’re paying for your healthcare then a sleep study is expensive, but it’s generally worth telling your GP what is going on at the very least.  Keeping a sleep diary for a while (a week, a month) can be very useful.  You will want to note down when you sleep, when you doze, when you get up, when you take any meds or treatments that can affect sleep or alertness, and optionally when you eat and get exercise.  If you have sleeping partners, ask what they’ve noticed (e.g. stopping breathing during sleep, waking up with amnesia).  I’m generally going to be talking about circadian rhythm disorders, such as Delayed Sleep Phase Syndrome (when you’re an extreme night owl, e.g. you can’t get to sleep earlier than 4 am no matter how hard you try) and Non-24 Sleep Wake Disorder (when your body clock is running on a 25 hour or 26 hour schedule, so that you will fall asleep an hour or so later every day, which is like living with permanent jet lag), as well as general insomnia and poor sleep quality.  If you have ME, chances are that your sleep will be poor no matter what you do, but it may be possible to improve it to quite an extent.