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Insomnia

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“Dependent on sleep are happiness and misery, corpulence and leanness, strength and weakness, potency and impotency, intellect and non-intellect, life and death.” Charaka Samhita Sutrasthana The Caraka Samhita (CS) is an early text on Ayurveda (Indian traditional medicine). It is one of the two foundational texts of Ayurveda dating back to the period of 900 BCE - 600 BCE.

Description

Insomnia describes when someone’s experience of sleep is not sufficient to leave them rested and refreshed. There are all sorts of different symptoms associated with insomnia such as difficulty getting to sleep, difficulty in staying asleep, waking early, restlessness at night, excessive dreaming, irregular sleep pattern. It often leads to feeling tired, inability to concentrate, increased anxiety and generally feeling ‘washed-out’. Many people suffer from occasional sleeplessness and about 10-15% of all adults suffer from some form of chronic sleep disturbance and a further 30% experiencing some form of transient insomnia. It is important to note that insomnia is often a subjective experience of not getting enough sleep. Whilst most people need eight hours of sleep to feel like they have had a good nights’ sleep many people can get by on much less.

There are multiple causes to insomnia from short-term stress to chronic pain, illness, anxiety and depression. Other causes may be reactive hypoglycemia, digestive disorders, menopausal night sweats, dermatitis, pruritus, late night alcohol consumption, caffeine consumption, recreational drugs, late night electronic stimulation (TV, computers, stimulating music), prostate problems, restless leg syndrome, magnesium deficiencies and B vitamin deficiencies. Of course, insomnia increases in the elderly with 50% of people over 70 years old experiencing a chronic form of insomnia. It is important to discover if the causes of insomnia are due to some of these external events or if the causes are more internal. If the external events can be changed then the insomnia can be cured. If insomnia is caused by itching, breathing difficulties, indigestion, prostate issues or pain then the diagnosis is not insomnia, though it should be included in the treatment.

Insomnia and depression are disorders that often go together. Up to 20% of people with insomnia disorder also fulfil criteria for major depression and for people with depression, 69% also report mild or moderate insomnia. Longitudinal studies have showed that insomnia is a well-established risk factor to develop depression and that more severe insomnia is associated with more severe depression. Together these results indicate that it is important to treat sleep problems as they mark a higher risk for future depressive episodes.

Insomnia can exacerbate any other illness or be caused by many illnesses. Either way it can acutely degrade the quality of life leading to chronic tiredness, stress and under performance.

Allopathic management of insomnia

Several different types of medications are used for treating insomnia. However, many doctors do not recommend relying on prescription sleeping pills for long-term use. Modern management of sleep disorders depends on the cause of the insomnia and may involve hypnotics, analgesics, anti-depressants and anti-histamines.

Certain classes of sedatives can also cause physical dependence, which manifests in withdrawal symptoms if the drug is not carefully tapered down. Hypnotic medications also can have a number of side-effects such as day time fatigue, motor vehicle crashes, cognitive impairments and falls and fractures. Elderly people are more sensitive to these side-effects.

Benzodiazepines: These drugs promote the action of the neurotransmitter gamma-aminobutyric acid (GABA) which binds to neurons and slows the transmission of electrical impulses between brain cells. This slows communication of thoughts, causes drowsiness and induces a drug-induced sleep. These drugs are normally recommended to be used only for transient and short-term insomnia, although in many cases end up being used on a long-term basis. Many of these drugs interfere with the normal sleep cycle, inhibiting both REM (Rapid Eye Movement) and NREM (Non-REM) sleep, and thus interfere with the restorative benefits of sleep. If they are used over a longer period of time they can lead to psychological and physical dependence. Sudden withdrawal leads to rebound effects of anxiety, insomnia and restlessness. Hypnotic benzodiazepines include drugs such as temazepam, clonazepam, lorazepam, oxazepam, diazepam etc.

Nonbenzodiazepines: are a class of psychoactive drugs that are very benzodiazepine-like in nature. Their pharmacodynamics are almost entirely the same as benzodiazepine drugs and therefore employ similar efficacy that is not significantly more than for antidepressants, similar side-effects, and risks. The non-benzodiazepines zolpidem and zaleplon have not adequately demonstrated effectiveness in sleep maintenance.

Barbiturates: Can cause heavy sedation and rarely used in clinic due to the tendency to cause dependency. Barbiturates have now largely been replaced by benzodiazepines in routine medical practice – in the treatment of anxiety and insomnia, because there is no specific antidote for barbiturate overdose.

Anti-histamines: Predominantly used to treat allergies. As an alternative to taking prescription drugs, some evidence shows that an average person seeking short-term help may find relief from taking antihistamines such as diphenhydramine or doxylamine. However, the anti-histamines that enter the brain can also cause drowsiness and the agents may decrease over time, whilst the incidence of next-day sedation is very high.

Anti-depressants: Selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs) are increasing levels of a group of chemicals in the brain called neurotransmitters like serotonin and noradrenaline which can improve mood and emotion. While antidepressants can help treat the symptoms of depression, they do not address its causes. Fluoxetine is probably the best known SSRI (sold under the brand name Prozac). Other are citalopram (Cipramil), paroxetine (Seroxat) and sertraline (Lustral).Examples of SNRIs include duloxetine (Cymbalta and Yentreve) and venlafaxine (Efexor). However, in some cases insomnia is experienced as one of its side effects.

Tricyclic antidepressants (TCAs) are an older type of antidepressant showing more unpleasant side effects than SSRIs and SNRIs. Examples of TCAs include amitriptyline (Tryptizol) - can have a sedative effect, and are prescribed to treat insomnia; clomipramine (Anafranil), imipramine (Tofranil), lofepramine (Gamanil) and nortriptyline (Allegron).

As with benzodiazepines, the use of antidepressants in the treatment of insomnia can lead to withdrawal effects.

Ayurvedic perspective on insomnia

 “Excessive detoxification, fear, anxiety, anger, smoking, exercise, blood-letting, fasting, an uncomfortable bed…these above mentioned factors may be taken as the causes of insomnia, along with overwork, old age, vatika disorders and aggravation of vata itself.”
Charaka Samhita Sutrasthana

As the seat of consciousness, the heart (hrdaya) plays a vital role in the ability to achieve peaceful sleep.From the heart the channels of prana (lifeforce), manas (mind)and rasa (plasma) all extend revealing it as the source of breath, mental balance and nutrition. The heart, as well as being a governing organ of blood circulation, is also the seat of consciousness (CS 1.30.4). So, the heart needs to be nourished with good quality prana from breathing pure air, thinking righteous thoughts and assimilating nutrients from food.

In Ayurveda a unique feature is that the dosha of each individual is determined based on the psychosomatic attributes of an individual’s personality. The doshas determine various basic functions, including sleep.

Insomnia usually involves vata or pitta, with kapha rarely being involved in insomnia. When there is a vata involvement then an excess of vata pushes prana upwards towards the head which increases thoughts and prevents relaxation. If there is depletion causing a hyper-activity, a type of ‘empty energy’, then vata is predominant. Our present life-styles create this pattern in people who are working very hard with little time to rest on a background of deep-set constitutional deficiency. High vata increases anxiety, fear and coldness which causes contraction of the whole body leading to what can be called an asthenic type of insomnia. This means that the person cannot relax and drift off into the blissful state of sleep. They especially have difficulty falling to sleep due to excessive thinking. They can also wake early between 4-6 am and be unable to get back to sleep.

Because of the association between the nervous system and vata, if there is any disorder in majja dhatu (nerve tissue), then this tissue will need to be treated.

However, insomnia may also involve high pitta with a pattern of heat, hot flushes, sweating, agitation, irritability and palpitations leading to what can be called a sthenic insomnia. These people are usually driven, active and may suffer from insomnia due to the excess of internal heat that is then compounded by additional anger, heating foods or fever. They often wake in the middle of the night with night sweats, palpitations and feeling hot.

The role of agni (digestive fire) in insomnia

As we know it is virtually impossible to discuss any imbalance of health without including the role of the digestive fire. Agni is at the heart of all assimilation be it physical, mental, emotional or spiritual. If agni is overloaded on any one of those levels then the ‘ingested’ substance or experience may just sit and fester on that level. Insomnia is a perfect example of how impaired mental-digestion can ‘clog’ the mind with excessive thoughts and lead to restlessness at night or the inability to sleep. Mental agni is helped by many of the suggestions below.

Ayurvedic management of insomnia

There are a number of things you can try to help yourself get a good night's sleep if you have insomnia. These include the following lifestyle suggestions:

Daily routine/rhythm: Set regular times for going to bed (between 10pm and 10:30pm) and waking up at around 6-7am depending on the time of year and your energy-exertion levels..

Relaxation before bed time: try taking a warm-aromatic bath or listening to calming music.

Enjoy a sleepy milk before going to bed:
1 cup cow’s, almond or rice milk
2 tsp organic almond powder
2 cardamom pods
5 strands saffron
pinch of nutmeg
warm all the ingredients and add 1 tsp honey (only when the milk is lip-warm). Take with Ashwagandha for deeper restoration.

Ashwagandha: Take with 1-2gs organic ashwagandha (Withania somnifera) at night. This helps to nourish the nervous system, reproductive system and helps you sleep. A recently published study indicates that key constituents in Withania somnifera (WS) may have an important role in the development of pharmacological treatments for neurological disorders associated with GABAergic signalling dysfunction such as general anxiety disorders, sleep disturbances, muscle spasms, and seizures. In addition, the differential activation of GABA receptor subtypes elucidates a potential mechanism by which WS accomplishes its reported adaptogenic properties.

Massage yourself using warm sesame or maharanayan oil and including essential oils of lavender, ylang ylang and rose. This will help to calm down the central nervous system and as a ritual it will help you to prepare yourself for a good night’s sleep.

Ensure lights are set to low by 9pm: using thick curtains or blinds, an eye mask and earplugs to stop you being woken up by light and noise

Writing a journal: writing down your worries and thoughts as well as any ideas about how to solve them before going to bed, to help you forget about them until the morning

Meditation: start with a simple meditation technique to let thoughts go before going to bed. It helps you break the train of your everyday thoughts to evoke the relaxation response, using whatever technique feels right to you.

To avoid:

  • caffeine, nicotine, alcohol, and exercise for a few hours before going to bed
  • watching TV or using phones, tablets or computers before going to bed 

Treatment strategies

  1. If there is depletion causing a hyper-activity, a type of ‘empty energy’, then vatais predominant often accompanied by anxiety, fear and coldness. The person cannot relax and drift off into the blissful state of sleep due to excessive thinking. They can also wake early between 4-6am and be unable to get back to sleep.
  2. High pitta shows a pattern of excess of internal heat, hot flushes, sweating, agitation, irritability and palpitations. These people are usually driven, active and they often wake in the middle of the night with night sweats, palpitations and feeling hot.

1. Treatment for Vata type insomnia

Give heavy, warm, unctuous, relaxing and sedative medicines such as:

Ashwagandha: Its Latin name is Withania somnifera reflecting its somnerific ability to induce sound and restorative sleep. Its heavy, warming and grounding qualities nourish vata and help it to calm and over-excited nervous system. It's a classic for that ‘running on empty’ feeling.

Nutmeg: a delayed onset sedative which is very good for transient insomnia where people wake up at night and cannot get back to sleep.

Oatstraw flowering tops: A long-term nourishing a sweet restorative to frazzled nerves and a burnt out system that finds it difficult to unwind or feel energised.

Valerian: Valerian root has sedative and anxiolytic effect due the interaction of some of its constituents such as valerenic acids, components of the essential oil along and other semivolatile sesquiterpenoids with the GABA receptor.

Jatamamsi (NOT TO BE USED AS IT IS CITES LISTED ENDANGERED SPECIES. See www.cites.org for more information. Included for historical reasons only): has a superb rejuvenating effect on the mind. It is a sought-after nervous relaxant and antispasmodic. It cools and nourishes a ‘hot’ and ‘exhausted’ nervous system; clears pitta and calms vata by virtue of its benefiting majja dhatu-agni it enhances the intellect and induces mental clarity.

If there is digestive problems use fennel, ginger, cumin, coriander, ajwain, and/or cardamom before and after meals.

2. Treatment for Pitta type insomnia

Use cooling, light, relaxing, calming remedies:

Arjuna: is acting on the heart and used to treat emotional disturbance and ‘broken heart’. It can be combined with Ashwagandha which nourishes the nervous system.

Brahmi: due to its biomedical actions including sedative, nervine, cardiotonic, antispasmodic and anticonvulsant, Brahmi is popular for its mind enhancing and nervous system soothing properties.

Chamomile: Also known as German Chamomile, these exquisite white-petaled yellow flowers are full of the sweetness that can help to relax the nervous system for both vata and pitta. Chamomile is used as a delicious tea to induce good sleep, settle restless legs and stop spasms. It also has a mild bitter flavour that makes it a wonderful digestive, helping to ease bloating, cramps and inflammation throughout the digestive system.

Gotu kola: Constituents like asiaticoside, brahmoside, brahminoside are determined to relax the nervous system in conditions of stress, insomnia, epilepsy, emotional turbulence. Furthermore Gotu kola balances all three doshas and has wondrous effects on the skin.

Hawthorn: hold significant potential in strengthening the heart and as a useful remedy in the treatment of palpitations, fatigue and exercise dyspnoea.

Limeflower: Herbal tea is taken to ease insomnia, relieve tension and anxiety, to calm children who are excitable or restless, and to reduce muscle tension. Due to the bioflavonoids in lime flower and its relaxing qualities, this herb is good for lowering high blood pressure.

Passionflower: The fresh or dried leaves are used to make a tea that is used for insomnia, hysteria, and epilepsy, and is also valued for its analgesic properties.

With night sweats add some bitter astringents: arjuna, ashoka, sariva, manjishtha.

It is not a good idea for pitta types to go to bed after 11pm, but they often do as pitta types like late nights. If pitta is already too high then they become over stimulated after 10pm.

Dietary solutions

  • It is essential to be eating foods that are easy to digest such as warm, cooked vegetables in soups and grains especially in the evenings in particular when vata is increased. Fasting and low calorie diets may interfere with sleeping patterns. Food sensitivities and high carbohydrate foods may cause indigestion and blood-sugar imbalances.
  • Avoid sour or acid and fermented foods (such as tomatoes, yoghurt, vinegar, cheese), excessively hot spices and high salt intake as these aggravate pitta.
  • Enkindle the digestive fire by following the essential dietary rules of Ayurveda such as appropriate food combining, eating within your capacity and not eating in between meals.
  • If there is bloating in the evening, take one to two teaspoons of castor oil to remove excess of vata from the colon.
  • Eliminate stimulants; coffee, methylxanthine containing foods (tea, chocolate, cola nut, guarana, yerba mate) and caffeine-containing medications
  • Avoid excessive alcohol as it may cause insomnia due to rebound hypoglycaemia causing night-time awakening
  • Help to maintain a good digestive fire when having regular meals using spices like cumin, turmeric, asafoetida, coriander, fennel, saffron, fenugreek and galangal.

Further herbs are recommended for the treatment of insomnia and can be enjoyed in a cup of tea: chamomile, lavender, and oatstraw flowering tops.

“If one suffers from insomnia they can be instantaneously cured by massage, oils, bathing, warm soups, rice pudding, a small glass of wine, being relaxed, pleasant essential oils, soothing music, palming, a comfortable bed and a peaceful home.”
Charaka Samhita Sutrasthana

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