To Sleep, Perchance to Dream

“Insomnia has a strong anxiety component,” explains Clinical Psychologist Dr. Miriam Adler, executive director of Park Avenue Psychotherapy & Neurofeedback Associates in Clifton, New Jersey. “For many people, part of the insomnia loop is that they get anxious about whether they are going to have insomnia. It starts with a night or two of difficulty falling asleep, and the next morning perhaps they can’t focus or they miss something important. From that point onward, they become anxious in the evening, worrying, ‘Am I going to get up tomorrow?’ They are so busy thinking about whether they will get a good night’s sleep that their brains can’t relax enough to make that happen.

“There is more shame when it’s a frum male who has difficulty waking up in the mornings,” asserts Dr. Adler. “Religious observance becomes part of a person’s self-concept. Now, instead of ‘I have a hard time getting out of bed,’ it’s ‘I don’t make minyan’—it becomes a bigger issue.”

Furthermore, because the Jewish calendar varies, it’s challenging to stick to a consistent sleeping schedule, generally a key component in treating insomnia.

“Obviously many people are able to have variances in their schedule without an insomnia problem,” Dr. Adler adds. “But for those who have more sensitive sleep-wake cycles or who have a history of sleep anxiety, a change in an evening routine is a monkey wrench. Many people need a certain amount of time to unwind before they can transition into a sleepier state. In the summer, if you have a late Friday night dinner, you may have a harder time falling asleep on those evenings and possibly a harder time waking up for shul the next day as well. This can also be a problem for boys who go to mishmar [late night learning sessions], as is typical in many yeshivah programs.”

TREATING INSOMNIA
“One of the first steps in treating insomnia is ruling out other causes,” says Kelly Brown, M.D., assistant professor of neurology at the Sleep Center at Vanderbilt University in Nashville, Tennessee, who is a sleep specialist. “Most of the time, when we treat the underlying cause, the sleep difficulty resolves itself.”

For example, undiagnosed sleep apnea (sleep interrupted by breathing difficulties) can lead to non-restful sleep. Another fairly common condition, periodic limb movement disorder, leads people to “kick themselves awake all night,” describes Dr. Brown. “It goes along with restless leg syndrome—when an individual is trying to fall asleep but feels like his legs need to move.” Undiagnosed anxiety or depression may also interfere with healthy sleeping. Dr. Brown has patients keep a sleep diary, tracking sleep habits like time spent in bed and amount of sleep to determine what is going on.

Once alternate causes have been addressed, sleep specialists use cognitive behavioral therapy (CBT) to help patients resolve sleep issues. “CBT works as well as sleeping pills in helping people fall asleep,” Dr. Brown asserts. “It also offers long-standing benefits, whereas pills only work when the patient is taking them.” Sleeping pills have been associated with negative side effects, like excessive drowsiness and increased morbidity and mortality, adds Dr. Brown.

Creating a consistent healthy sleep routine, what’s known as sleep hygiene, is one component of CBT for insomnia. (See sidebar for specific sleep hygiene strategies.) “Just like for a young child we schedule dinner at X time, then bath, then bed,” describes Dr. Adler, “sticking to a schedule [for adults] sets up both body and mind to transition into sleep.”

Another strategy is sleep restriction—limiting the time spent awake in bed—which helps associate the bed with sleep. If you’re lying in bed unable to fall asleep, Dr. Brown recommends getting out of bed and doing a quiet activity like reading until you feel drowsy again.

Because of the anxiety component, it’s helpful to learn to shut off worrisome thoughts that are keeping you awake. Dr. Adler suggests focusing on relaxing and being comfortable, rather than thinking about falling asleep.

Relaxing does not come naturally to everyone, but training with a therapist can help. “People with insomnia often benefit from learning calming activities like deep breathing and guided imagery, which help transition the brain into a less active, more tranquil state,” Dr. Adler says.

“In more extreme cases, I recommend neurofeedback, a system which helps people monitor their brainwaves and train their brains to shift more easily into the deeply relaxing delta brainwaves needed for satisfying sleep quality. Some people naturally have a deficit of delta brain waves,” Dr. Adler adds.

NUTRITION AND INSOMNIA
A key nutrient of concern in sleeping difficulties is iron. “Iron deficiency is associated with restless leg syndrome; it can go away once iron is replaced,” explains Dr. Brown.

A recent study from the Journal of Sleep Research used information from national surveys to pinpoint several other food and lifestyle habits related to sleep challenges. For instance, dieting and eating few foods and calories make people more likely to be sleepy during the day and have a hard time falling asleep at night. This might be due to simple hunger; it’s hard to nod off when your growling stomach is telling you to head to the kitchen.

Researchers also identified a handful of nutrients that may have a relationship to sleep. A lower intake of selenium (found in meat, dairy, grains and nuts) is linked to having a hard time falling asleep and an increased intake of calcium (found in dairy products, fortified foods and certain vegetables, nuts and beans) is associated with enabling one to fall asleep more easily.

However, iron aside, it’s not so helpful to focus on individual nutrients since foods contain a combination of nutrients. An overall healthy diet rich in fruits and vegetables and other wholesome foods should help you get a good night’s sleep.

There’s a connection between large quantities of caffeine and insomnia: caffeine is thought to disrupt normal sleep cycles. Many people need to avoid consuming caffeine from the afternoon on. Alcohol may similarly break up sleep during the night so it’s less restful, according to research. Alcohol also suppresses REM (rapid eye movement) sleep, the stage in which you dream.

WHAT ABOUT KIDS?
The same types of strategies can be used for a child struggling with insomnia (sleep troubles tend to run in families): a consistent bedtime routine, a period of winding down before bed and a strict no electronics rule in the bedroom. Children can be taught to release anxious thoughts, use guided imagery and focus on feeling comfortable in bed.

Regardless of age, if sleep difficulties interfere with daily activities, consider seeing a sleep specialist who will take a thorough history of your sleep habits to help determine the cause and best course of treatment.

Should I Take Melatonin?
Melatonin, produced by the pineal gland in the brain, is normally found in our bodies. It regulates circadian rhythms and helps you both fall asleep and stay asleep. As people get older, levels of melatonin drop off, which may partly explain why some older individuals have a harder time falling asleep. Despite the fact that melatonin is a hormone, in the United States, melatonin is considered a dietary supplement by the Food and Drug Administration. Though it is generally considered safe, it’s not subject to the same types of regulation as a drug, and can be bought without a prescription in any dosage.

Taking too much melatonin at a time can cause side effects, such as feeling hungover. Supplemental melatonin may make you more tired; be wary if you’ll be driving or operating machinery after taking it. It also can lower blood pressure at night. As with any supplement, consult your healthcare provider before taking melatonin.

Melatonin is not specifically recommended for children because of a lack of study on its safety and efficacy in this age group. Some small short-term studies have focused on certain subgroups, like children with attention deficit hyperactivity disorder (ADHD) or autism, and have found melatonin to be beneficial with little risk of side effects. Talk with your pediatrician before giving melatonin or any supplement to your child.

Shira Isenberg is a registered dietitian and writer with a private nutrition practice in Memphis, Tennessee. She has a master’s degree in public health nutrition from Hunter College in New York.