Humans evolved to be asleep when it is dark and be awake when it is light. Sleep is a form of hibernation when the body shuts down in order to repair damage done through use, to conserve energy and hide from predators. The normal sleep pattern that evolved in hot climates is to sleep, keep warm and conserve energy during the cold nights and then sleep again in the afternoons when it is too hot to work and hide away from the midday sun. As humans migrated away from the Equator, the sleep pattern had to change with the seasons and as the lengths of the days changed.
Sleep is Essential for Life
After the First World War a strain of Spanish 'flu swept through Europe killing 50 million people worldwide. Some people sustained neurological damage and for some this virus wiped out their sleep centre in the brain. This meant they were unable to sleep at all. All these poor people were dead within 2 weeks and this was the first solid scientific evidence that sleep is more essential for life than food and water. Indeed all living creatures require a regular "sleep" (or period of quiescence) during which time healing and repair takes place. You must put as much work into your sleep as your diet. Without a good night's sleep on a regular basis all other interventions are undermined.
Get the Physical Essentials For a Good Night's Sleep Sorted
We are all creatures of habit and the first essential is to get the physical essentials in place.
- A regular pre-bedtime routine - your "alarm" should go off at 9pm at which point you drop all activity and move into your bedtime routine.
- A regular bed time - 9.30pm latest! Perhaps earlier in winter.
- Learn to recognize the sleep wave - one comes every 90 minutes
- Learn a "sleep dream" to train the subconscious to switch on the sleep button!
- Your day needs the right balance of mental and physical activity.
- Do not allow a bed fellow who snores - you need different rooms!
- A high fat low carbohydrate snack just before bedtime (eg nuts, seeds) helps prevent nocturnal hypoglycaemia which often manifests with vivid dreams or sweating or waking in night. Hypoglycaemia - the full story is the commonest reason for disturbed sleep. However some people find any food disturbs sleep and they sleep best if they do not eat after 6pm.
- Perhaps restrict fluids in the evening if your night is disturbed by the need to pee.
- No stimulants such as caffeine or adrenaline inducing TV, arguments, phone calls, family matters or whatever before bed time! Caffeine has a long half life - none after 4pm.
- Dark room - the slightest chink of light landing on your skin will disturb your own production of melatonin (the body's natural sleep hormone) - have thick curtains or blackouts to keep the bedroom dark - this is particularly important for children! Do not switch the light on or clock watch should you wake.
- A source of fresh, preferably cool, air.
- A warm comfortable bed - we have been brainwashed into believing a hard bed is good for us and so many people end up with sleepless nights on an uncomfortable bed. It is the shape of the bed that is important (see section on posture Poor posture - a common cause of low back pain. How to correct it). It should be shaped to fit you approximately and then very soft to distribute your weight evenly and avoid pressure points. Tempur mattresses can be helpful (if expensive) as are water beds.
- If your sleep is disturbed by heat and sweating then this is likely to be a symptom of low blood sugar.
- Another common cause of disturbed sleep is hyperventilation which often causes vivid dreams or nightmares. I suspect much hyperventilation is adrenalin driven from nutritional stress (hypoglycaemia) or psychological stress. See my section on Hyperventilation - this can now be tested for by measuring a Carbonic anhydrase studies in red blood cells However I often use a benzodiazepine, such as diazepam 2-5mgs at night, which reduces the sensitivity of the respiratory centre.
- If sleep is disturbed by pain, try to find the cause of the Pain. If this is not possible, then one must just take whatever pain killers are necessary to control this. Lack of sleep simply worsens pain.
- If one wakes in the nights with symptoms such as asthma, chest pain, shortness of breath, indigestion etc then this may point to food allergy being the problem with these withdrawal symptoms occurring during the small hours.
- If you do wake in the night do not switch the light on, do not get up and potter round the house or you will have no chance of dropping off to sleep. Use again your sleep dream.
Get the Hours of Sleep
People needed more sleep during the winter than in the summer in order to conserve energy and fat resources. Furthermore during the summer, humans had to work long hours to store food for the winter and so dropped the afternoon siesta. But the need for a rest (if not a sleep) in the middle of the day is still there. Therefore it is no surprise that young children, elderly and people who become ill often have an extra sleep in the afternoon and for these people that is totally desirable. Others have learned to "power nap", as it is called, during the day and this allows them to feel more energetic later. If you can do it then this is an excellent habit to get into - it can be learned! The average daily sleep requirement is nine hours, ideally taken between 9.30pm and 6.30am, i.e. during hours of darkness, but allow for more in the winter and less in the summer. An hour of sleep before midnight is worth two after - this is because human growth hormone is produced during the hours of sleep before midnight.
To show how important the balance of hours of sleep and rest are, divide the day into 12 hours of activity and 12 hours of rest. If you have one extra hour of activity (13 hours), you lose an hour of rest and sleep (11 hours). The difference is two hours!
Sleep When it is Dark
Light on the skin prevents the production of melatonin, which is the sleep hormone essential for a good night's sleep. Therefore, the bedroom should be completely blacked out and quiet in order to give the best chance of quality sleep. Even people who are born blind still have a day night rhythm - it is light landing on the skin which has the effect - just closing your eyes will not do it! A study done in 1907 before electricity was available showed that people went to bed when it got dark and rose when it got light. On average through the year they got 9 hours sleep, more in winter, less in summer. Nowadays we average 7 and a half hours of sleep - we are losing on average 550 hours of sleep a year! Loss of sleep is a major risk factor for heart disease, cancer and degenerative conditions! We damage our cells during wakening hours, and heal and repair during sleep - get the balance wrong and one ratchets downhill with time with not enough time to heal and repair the damage created during wakeful hours!
The commonest cause of disturbed sleep in the night is Hypoglycaemia
Once the Stone Age Diet is established, this often helps considerably with sleep, but in the meantime have a snack last thing at night (eg. nuts and seeds with a small piece of fruit) and, if disturbed, maybe eat again in the night. In fact, more often I now prescribe the ketogenic diet - please see Ketogenic diet - the practical details and My book The PK Cookbook - Go Paleo-ketogenic and get the best of both worlds.
Recognize the Sleep Wave
Actually sleep does not gradually creep up on us during the evening - it comes in waves. There is a sleep wave about every 90 minutes and you will get to sleep most efficiently if you learn to recognise and ride the sleep wave. Often there is a lesser one earlier in the evening when people drop off to sleep in front of the telly, or they jump and make a cup of tea to wake themselves up because "they are not ready to go to bed" - actually they are! My sleep wave comes at 9.20 and I like to be in bed reading well before this - it is immediately recognisable now and I have learnt to expect it!
Get the Brain Off to Sleep
Getting the physical things in place is the easy bit. The hard bit is getting your brain off to sleep. I learned an astonishing statistic recently which is that throughout life, the brain makes a million new connections every second!! This means it has a fantastic ability to learn new things. This means it is perfectly possibly to teach your brain to go off to sleep, it is simply a case of pressing the right buttons. Getting off to sleep is all about developing a conditioned reflex. The first historical example of this is Pavlov's dogs. Pavlov was a Russian physiologist who showed that when dogs eat food, they produce stomach acid. He then "conditioned" them by ringing a bell whilst they ate food. After two weeks of conditioning, he could make them produce stomach acid simply by ringing a bell. This of course is a completely useless conditioned response, but it shows us that the brain can be trained to do anything.
Applying this to the insomniac, firstly, he has to get into a mind-set which does not involve the immediate past or immediate future. That is to say if he is thinking about reality then there is no chance of getting off to sleep - more of this in a moment. Then he uses a hypnotic (see below) which will get him off to sleep. He applies the two together for a period of "conditioning". This may be a few days or a few weeks. The brain then learns that when it gets into that particular mindset, it will go off to sleep. Then the drug becomes irrelevant. However, things can break down during times of stress and a few days of drug may be required to reinforce the conditioned response. But it is vital to use the correct "mind-set" every time the drug is used, or the conditioning will weaken.
I do not pretend this is easy, but to allow one's mind to wander into reality when one is trying to sleep must be considered a complete self-indulgence. Treat your brain like a naughty child! It is simply not allowed to free-wheel.
Find a Sleep Dream That Suits You
Everyone has to work out their best mind-set. It could be a childhood dream, or recalling details of a journey or walk, or whatever. It is actually a sort of self-hypnosis. What you are trying to do is to "talk" to your subconscious. This can only be done with the imagination, not with the spoken language.
We know that the hypnotic state is characterised by extreme responsiveness to suggestion. You can use this information for conditioning yourself in self hypnosis. Here is a standard procedure to follow. Lie down in bed, ready for sleep initially with your eyes open (the room needs to be dark). Mentally give yourself the suggestion that your eyes are becoming heavy and tired. Give yourself the suggestion that as you count to ten, your eyes will become very heavy and watery and that you will find it impossible to keep your eyelids open by the time you reach ten. If you find that you cannot keep them open and have to close them, then you are probably under self-hypnosis. At this point deepen the state by again slowly counting to ten. Between each count mentally give yourself suggestions that you are falling into a deep hypnotic state. Give yourself suggestions of relaxation. Try to reach a state where you feel you are about to fall asleep. Give yourself the suggestion that you are falling more deeply down into sleep. Some may get a very light feeling throughout the body; others may get a heavy feeling.
Let us assume that your eyes did not become heavy. Then repeat the procedure. You can count to one hundred if you need this period of time to assure an eye closure. The closing of the eyes is the first sign you are in a receptive frame of mind. Let us assume that you get the eye closure. Take a longer count to get yourself in the very relaxed state. Once you achieve this, you should be able to respond properly. The difficult bit is not allowing your brain to wander off into other areas. You must work hard at concentrating on the counting and the responses that achieves.
If you respond properly, give yourself the "post-hypnotic suggestion" that you will be able to put yourself under later by counting to three, or using any specific phrase you desire. Continue using it every day and give yourself the post hypnotic suggestion every time you work with it, that at each succeeding session you will fall into a deeper state and that the suggestions will work more forcefully with each repetition.
Each time that you work towards acquiring the self-hypnotic state, regardless of the depth that you have achieved and whether or not you have responded to any of the tests, give yourself the following suggestions: "The next time I hypnotise myself, I shall fall into a deeper and sounder state." You should also give yourself whatever suggestions you desire as though you were in a very deep state of hypnosis. You may ask "If I'm not under hypnosis, why give myself the suggestions?" You do this so that you will begin to form the conditioned reflex pattern. Keep at it. One of the times that you work at achieving self-hypnosis the conditioned response will take hold.....you will have self hypnosis from that time on. It is like learning to drive a car with a clutch. At first you must consciously go through the process of putting your foot on the clutch and shifting gears. Usually there is a grinding of the gears and you feel quite conspicuous about this, but gradually you learn to do this almost automatically and you gain confidence in your driving ability. The same is true of hypnosis. As you work at you task, you gradually get the feel of it and you achieve proficiency in it.
My Sleep Dream
I dream that I am a hibernating bear, snuggled down in my comfortable den with one daughter in one arm and the other in the other. Outside the wind is howling and the snow coming down and I am sinking deeper and deeper down.....
Use Medication to Reinforce the Sleep Dream
I instinctively do not like prescribing drugs. However, I do use them for sleep, in order to establish the above conditioning and to restore a normal pattern of sleep, after which they can be tailed off or kept for occasional use. Indeed, viruses can cause neurological damage (for example polio) and this could involve damage to the sleep centre. So often CFS patients get into a bad rhythm of poor sleep at night, which means they feel ill for the day, which means they get another bad night. They are half asleep by night and half awake by day. Furthermore, their natural time for sleep gets later and later. They go to bed late and if they have to get up at the usual time, chronic lack of sleep ensues. Indeed there is now evidence that the biological clock is dependent on normal adrenal function - and we know this is suppressed in CFS.
So often some medication is needed to facilitate sleep. Most CFS patients react badly to drugs in normal doses. I like to use combinations of low dose herbals, natural remedies and prescribed drugs to get the desired effect. Everybody works out his or her own cocktail which suits. This may have to be changed from time to time. I like to supply a "starter pack" which has a selection of hypnotics to try. Please contact my office for a starter pack if you would like to try this. Once you have worked out your best combination you can either order it from me, or your GP or whatever is easiest. Please note that I am only able to prescribe the sleeping drugs, and any other prescriptiom medication to my patients and not members of the public. But anybody can purchase and use melatonin (from uk.iherb.com link for melatonin ), valerian and Nytol. Another supplier of melatonin is biovea.net/uk link for melatonin.
I am always asked about addiction. My experience is that this is rare, especially if drugs are used as above to develop a conditioned reflex. One has to distinguish between addiction and dependence. We are all dependent on food, but that does not mean we are addicted to it. We are all dependent on a good night's sleep for good health and may therefore become dependent on something to achieve that. This does not inevitably lead to addiction. Addiction is a condition of taking a drug excessively and being unable to cease doing so without other adverse effects. Stopping your medication may result in a poor night's sleep but no more than that. This is not addiction but dependence.
Natural Preparations and Prescription Drugs to Help Sleep
These all work differently and so I like to use low dose combinations until you find something that suits. Choose from the following, and start with:
- Melatonin 3mgs (one tablet) 1-3 tablets at night. Some people just need 1mg. CFS patients have a poor output of hormones from all their glands namely the hypothalamus, pituitary, adrenals, thyroid and also the pineal gland. The latter is responsible for producing melatonin, the natural sleep hormone. It seems logical to me therefore to try this first. I can supply some in the initial sleep "starter pack" to my patients only.
One or two of my patients have become depressed with melatonin, so be aware of this. On the container it also states melatonin should be avoided in autoimmune disorders, but I can find no reason why this should be so.
- Valerian root 400 mg 1-4 capsules at night. This is a herbal preparation which is shorter acting and can be taken in the middle of the night.
- Nytol (diphenhydramine 50mg). This is a sedating antihistamine available over the counter. The dose is 1-2 at night. This is longer acting - don't take in the middle of the night or you will wake up feeling hungover.
If there is no improvement with a combination of the above, or if there are intolerable side effects, then I would go on to a prescribed drug. I usually start with one of the sedating antidepressants such as:
- Amitriptyline 10mgs - 25mgs. I would start with 5mg initially. Most CFS patients are made worse and feel hungover with "normal doses".
- Surmontil 10-30mgs at night.
- Short acting temazepam 10mgs. This is useful but recently has been made a controlled drug and so doctors are understandably twitchy about prescribing it. It is controlled because some drug addicts were taking the gel and injecting it into themselves. Nowadays I tend to use instead zaleplon (Sonata) or medium acting zopiclone (Zimovane)7.5mg.
- Diazepam is helpful if sleep is disturbed either because of hyperventilation (it reduces the respiratory drive) or for muscle spasms (it is a good muscle relaxant).
Different people will respond to different combinations of hypnotics. For example, one person may take a melatonin and two valerian at night, plus a zaleplon when they wake at 3.00am. Somebody else may be best suited by 10 mg amitriptyline at night with a Nytol. Don't be afraid to try combinations - there are no serious side effects that I am aware of with any of these used in combination. However, don't change more than one thing at any time otherwise you (and I) will get confused!
I like to supply a "starter pack" to my patients - this contains melatonin, valerian and Nytol. Once you have worked out your best combination, you can either order it from me or ask your GP to prescribe.
One of my patients has found Sea Band (Isocones) very helpful - this uses an acupuncture technique by applying a wrist band - this is available from Boots. See www.sea-band.com.
Please, allow a week to receive your order.
The herbal "starter pack" consists of:
- valerian complex 30 capsules
- Nytol one a night 8 tablets
- melatonin 3 mgs 20 tablets
(Please contact my office for a starter pack if you would like to try this - www.drmyhill.co.uk)
If you find your dose of hypnotic is gradually creeping up, then this may be because you have become less disciplined about establishing the conditioned reflex. Go back to the basics as above.
The deal is that every time you take a tablet for sleep you must work hard on the self hypnosis methods in order to condition yourself to sleep! We all are given the gift of sleep as babies, then unlearn it! It is perfectly possible to relearn sleep!
When your normal sleep pattern has been restored you can begin to reduce or tail off completely your hypnotic medication but only if good quality sleep can be maintained. Use the hypnosis techniques every time you try to go to sleep, even when your sleep is disturbed by the need to pee - eventually your brain will learn! If your sleep begins to suffer, you must go back on the medication that worked before because the need to sleep is of paramount importance in CFS patients.
Other Causes of Poor Sleep
Get the right hormonal balance:
- High levels of DHEA mean low levels of melatonin. Check this with an Adrenal Stress Profile. This is a saliva test.
- Hypothyroidism can certainly present with insomnia.
- Hyperventilation - makes you feel as if you can't get your breath.
- Hypoglycemia can be a major main cause.
- Menopause – possible causes of hot flushes and what we can do to mitigate them
- Bio-rhythms or circadian rhythm