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Insomnia
Dr. James F. Balch

Habitual sleeplessness is classified as insomnia. Failure to get an entire night's sleep on most nights over a one-month period can be considered chronic insomnia. It affects one out of ten Americans (about 40 million) and approximately 30 percent of healthy seniors. Insomnia can take the form of being unable to fall asleep when you first go to bed or waking during the night and being unable to go back to sleep. While insomnia can be very frustrating, it is hardly dangerous and is usually only a temporary annoyance, although in some cases sleep-related problems can last for months or even years.

Chronic insomnia is often a symptom of a serious underlying medical disorder. Fifty percent of insomnia cases can be attributed to depression and psychological disorders, such as anxiety, stress, or grief. Insomnia can result from a wide variety of causes, including arthritis, asthma, breathing problems, hypoglycemia, hyperthyroidism, indigestion, kidney or heart disease, muscle aches, Parkinson's disease, or physical pain. Caffeine consumption, jet lag, and the use of certain drugs, including many antidepressants, the anti-seizure medication phenytoin (Dilantin), most appetite suppressants, beta-blockers (medications used for high blood pressure and heart ailments), the decongestant pseudoephedrine (found in many cold and allergy remedies), and thyroid hormone replacement drugs can also lead to insomnia.

A lack of the nutrients calcium and magnesium can cause you to wake up after a few hours and not be able to return to sleep. Systemic disorders involving the brain, digestive system, endocrine system, heart, kidneys, liver, lungs, and pancreas all may affect sleep, as can poor nutritional habits and eating too close to bedtime. A sedentary lifestyle can be a major contributor to sleep disorders.

While one or two sleepless nights can cause irritability and daytime sleepiness, with decreased ability to perform creative or repetitive tasks, most people can adapt to short term periods of sleep deprivation. After more than three days, however, sleep deprivation begins to cause a more serious deterioration in overall performance and can even result in mild personality changes. If chronic, inadequate sleep compromises productivity, creates problems in relationships, and can contribute to other health problems.

There are no hard and fast rules about how much sleep is enough, because every individual's requirements are different. Some people can function on as little as five hours of sleep a night, while others seem to perform better with nine, ten, or even more hours of sleep. Most adults need about eight hours of sleep nightly in order to feel refreshed and operate at peak efficiency during the day. Children, especially very young children and adolescents, generally require more sleep than adults to be at their best. It is not uncommon for people to sleep less as they get older, especially after the age of sixty.

Millions of people have trouble getting to sleep due to a condition commonly known as restless leg syndrome (RLS). For reasons unknown, when these people are in bed, their legs jerk, twitch, and kick involuntarily. Restless leg syndrome has also been linked to the painful nighttime leg muscle cramps that afflict so many people. A deficiency of magnesium may be involved in RLS, and some research strongly suggests that anemia may play a major role in this annoying disorder.

Sleep apnea affects about 20 million Americans and is a potentially serious sleep disorder. This problem is commonly associated with snoring and extremely irregular breathing throughout the night. In sleep apnea, breathing actually stops for as long as two minutes at a time while the individual is asleep. When breathing stops, the level of oxygen in the blood drops, resulting in oxygen deprivation. The individual then awakens, startled and gasping. A person with sleep apnea may awaken as many as 200 times throughout the night. The affected individual may not remember these awakenings, but anyone else who is awake at the time can naturally become alarmed when a person with sleep apnea stops breathing. In the less common form, central sleep apnea, breathing is stopped, not because the airway is closed, but because the diaphragm and chest muscles stop working.

Aside from disrupting normal sleep and causing extreme sleepiness during the day, sleep apnea is associated with other, more serious, health problems. People who have sleep apnea tend to have higher than normal blood pressure and are more likely to have strokes than the general population, and they also face an increased risk of heart disease, although the reason or reasons for these links are not known. People with sleep apnea also seem to have a higher-than-normal incidence of emotional and psychotic disorders. Experts attribute this to what they call a "dream deficit" -a lack of adequate rapid-eye-movement (REM) sleep, the stage of sleep in which dreaming occurs. A person with sleep apnea often cannot settle into REM sleep for even the eight to twelve seconds it takes to have a normal, healthy dream. While there is much about the phenomenon of dreaming that is not understood, it is known that prolonged periods of REM-sleep deprivation can induce various psychoses and other serious emotional disorders.

RECOMMENDATIONS:

* In the evening, eat bananas, dates, figs, milk, nut butter, tuna, turkey, and whole grain crackers, or yogurt. These foods are high in tryptophan, which promotes sleep. Eating a grapefruit half at bedtime may also help.

* Avoid alcohol. A small amount can help induce sleep initially, but it invariably disrupts deeper sleep cycles later.

* Avoid tobacco. While smoking may seem to have calming effect, nicotine is actually a neuro-stimulant an can cause sleep problems.

* Avoid stimulants, such as caffeine-containing beverages, after lunch.

* Avoid heavy meals three hours before bedtime.

* Avoid bacon, cheese, chocolate, eggplant, ham, potatoes, sauerkraut, sugar, sausage, spinach, tomatoes, and wine close to bedtime. These foods contain tyramine, which increases the release of norepinephrine, a brain stimulant.

* Avoid taking nasal decongestants and other cold medications late in the day. While many ingredients in the preparations are known to cause drowsiness, they can have the opposite effect on some people and act as a stimulant.

* Establish a set of habits and follow them consistently to establish a healthy sleep cycle. Among them:

• Go to bed only when you are sleepy.

• Do not stay in bed if you are not sleepy. Get up and move to another room and read, watch television, or do something quietly until you are really sleepy.

• Use the bedroom only for sleep and sex-not for reading, working, eating, or watching television.

• Set an alarm clock and get out of bed at the same time every morning, no matter how you slept the night before. Once normal sleep patterns are reestablished, most people find that they have no need for an alarm clock.

• Do not nap during the day if this isn't a normal thing for you to do.

• Exercise regularly in the late afternoon or early evening--'-but not right before bedtime. Physical exertion is an excellent way to make your body tired so that sleep comes about more easily.

• Take a hot bath (not a shower) an hour or two before bedtime. For further relaxation, put several drops of a soothing essential oil such as chamomile (if you are not allergic to ragweed) in the bath water.

• Learn to put worries out of your mind. If you have occasional trouble getting to sleep, concentrate on pleasant memories and thoughts. Recreate a pleasurable time or event in your life and relive it in your mind. Learning a relaxation technique such as meditation or the use of guided imagery is extremely helpful in getting sleep patterns back to normal for many people.

* One of the best remedies for insomnia is taking 5 milligrams of melatonin one hour before bedtime. If you feel groggy in the morning, reduce the dosage the next time you use it. Certain drugs frequently prescribed for older adults, including beta-blockers (for high blood pressure) and even aspirin, can lower melatonin levels. Caution: Do not overuse melatonin; use only as an occasional sleep aid.

* If you snore, try sleeping on your side. Sleep on a couch for a few nights to become accustomed to sleeping on your side.

Other Considerations:

* During sleep, the body's systems are still controlling basic functions. Nutrients are essential for the body and are used during the sleep cycle.

* A lack of sleep can encourage serious illness and cause premature aging. Experts recommend at least eight hours of sleep per night.

* Women's Health Advisor reports that an estimated 10 percent of all Americans suffer from restless legs syndrome (RIS), a disorder marked by uncomfortable urges to move the legs, especially just before falling asleep. Various treatments have been attempted for restless leg syndrome, but nothing seems to work consistently for everyone. The drug pramipexole (Mirapex) has shown positive benefits for some people with this condition. We believe that taking the proper vitamin and mineral supplements is the best approach to this problem. The supplements that help this condition more than anything are calcium, potassium, magnesium, and zinc. The following nutrients may prevent restless leg syndrome and leg cramps: 400 milligrams of B complex, 1,000 milligrams of magnesium, and 400 international units of vitamin E (d-alpha-tocopherol) per day.

* Regardless of how many hours of sleep you get each night, if you wake tip easily in the morning, and especially if you rarely (or ever) need the services of your alarm clock, and if you can make it through the entire day without seeming to run out of steam or feeling drowsy after sitting quietly or reading for a while, you are probably getting enough sleep.

* Research psychologist Dr. James Penland believes that a large number of women are suffering from copper and iron deficiencies, and that these deficiencies can cause insomnia. A hair analysis can reveal whether you have a deficiency.

* The hormonal shifts that occur during premenstrual syndrome and menopause may trigger insomnia. Estrogen affects the production and balance of the brain chemicals responsible for wakefulness.

* Anyone who snores excessively should be evaluated for sleep apnea. Many cases of sleep apnea respond to such measures as allergy treatment, weight reduction, or a simpIe laser surgery procedure to remove obstructions in the nasal passages.

* Millions of Americans consciously choose to skimp on their sleep in the mistaken belief that sleeping fewer hours allows them to be more productive. Many people even look on the fact that they can "get by" on so few hours of sleep as a badge of honor. In fact, however, they are likely doing themselves a great deal of harm in the long run. Moreover, the night owls who sleep less to accomplish more are actually less creative and less productive than those who get adequate amounts of sleep. Dr. Richard Bootzin, professor of psychology and director of the insomnia clinic at the University of Arizona Sleep Disorders Center, conducted long-term research into normal sleep habits and patterns. He discovered that people who get seven to eight hours of sleep each night live longer, happier, healthier lives than those who skimp on their sleep.

* Sleep therapists and other experts are greatly divided about the virtues of napping. While some maintain that napping is not necessary for people• who are well rested, others say it is a natural human tendency and should not be discouraged. There have been studies that seem to demonstrate that productivity is higher and the incidence of accidents lower in countries where napping is common. Consistency is probably the most important factor. While it is usually most advisable to consolidate all sleeping into one time period, if you regularly take an afternoon nap and you do not suffer from any sleeping disorders, then giving up naps might actually cause a disruption in your sleeping habits. If you nap, keep your naps short-less than an hour-and make sure that they are a regular part of the daily routine, not a now-and-then proposition.

* Sleep experts advise that people with insomnia avoid caffeine, but many people who are accustomed to drinking coffee late in the day and in the evening hours have been known to have their sleep cycles disrupted if they give up drinking coffee. This seems to bear out the idea that maintaining a steady routine is the most important factor in establishing a healthy sleep pattern. Of course, this applies only to those who are not experiencing any difficulties with their sleeping habits. Anyone who develops a bout of insomnia should consider eliminating all caffeine from his or her diet.

* Many people who suffer from insomnia resort to sleeping pills, whether over-the-counter or prescription medications. Sleeping pills do not cure insomnia, however, and they can interfere with REM sleep. The continued use of pharmacological sleeping aids can eventually lead to disruption of all the deeper stages of sleep. Researchers have found that up to 50 percent of people who take sleeping pills on a regular basis actually find that their insomnia becomes worse. The persistent use of sleeping pills also leads to dependency, either psychological or physical. The use of sleep medication should therefore be reserved for those whose insomnia has a physical basis, and then only as a temporary solution.

* People who take sleeping pills on a regular basis are 50 percent more likely than other people to die in accidents. Drowsiness accounts for 200,000 to 400,000 automobile accidents every year, and is responsible for two-thirds of all industrial mishaps, most common among shift workers in the early morning hours. Sleeping pills are also the third most commonly used means in suicide and are implicated in one-third of all drug-related suicide attempts and deaths.

* Over-the-counter sleep aids can cause a wide range of side effects, including agitation, confusion, depression, dry mouth, and worsening of symptoms of enlarged prostate.

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Alternative Treatments for Insomnia
By Liz Swain

Insomnia is the inability to obtain an adequate amount or quality of sleep. The difficulty can be in falling asleep, remaining asleep, or both. People with insomnia do not feel refreshed when they wake up. Insomnia is a common symptom affecting millions of people that may be caused by many conditions, diseases, or circumstances.

According to a 1999 American Medical Association (AMA) report, approximately 30% of adults in the United States suffer occasionally from insomnia and 10% experience chronic insomnia.

Description

Sleep is essential for mental and physical restoration. It is a cycle with two separate states: rapid eye movement (REM), the stage in which most dreaming occurs; and non-REM (NREM). Four stages of sleep take place during NREM: stage I, when the person passes from relaxed wakefulness; stage II, an early stage of light sleep; stages III and IV, which are increasing degrees of deep sleep. Most stage IV sleep (also called delta sleep), occurs in the first several hours of sleep. A period of REM sleep normally follows a period of NREM sleep.

Sleeplessness or insomnia is a symptom and may be caused by "stress, anxiety, depression, disease, pain, medications, sleep disorders, poor sleep habits .. [and] sleep environment and health habits," according to the National Sleep Foundation (NSF).

Women are 1.3 times more likely to report insomnia than men, according to the NSF. Women may experience sleeplessness before and at the onset of the menstrual cycle, during pregnancy, and menopause. The foundation reported that people over the age of 65 are "more likely to complain of insomnia than younger people." Furthermore, people who are divorced, widowed, or separated are more likely to have the problem than those who are married. In addition, insomnia is more frequently reported by those with lower socioeconomic status.

Insomnia is classified both by its nightly symptoms and its duration. Sleep-onset insomnia refers to difficulty falling asleep. Maintenance insomnia refers to waking frequently during the night or waking early. Insomnia is also classified in relation to the number of sleepless nights. Short-term or transient insomnia is a common occurrence and usually lasts only a few days. Long-term or chronic insomnia lasts more than three weeks and increases the risk for injuries in the home, at the workplace, and while driving because of daytime sleepiness and decreased concentration. Chronic insomnia can also lead to mood disorders like depression.

Insomnia comes with a high price tag for the nation. NSF in 1999 reported that an estimated $14 billion was spent in one year on such direct costs as insomnia treatment, healthcare services, and hospital and nursing home care. Annual indirect costs like work loss, property damage from accidents, and transportation to and from health care providers were estimated at close to $28 billion. Furthermore, insomnia accounted for $18 billion in lost productivity, according to a 1997 National Sleep Foundation survey.

Causes & symptoms

Transient insomnia is often caused by a temporary situation in a person's life, such as an argument with a loved one, a brief medical illness, or jet lag. When the situation is resolved or the precipitating factor disappears, the condition goes away, usually without medical treatment.

Such prescription drugs as asthma medicine, steroids, and anti-depressants can cause insomnia. Sleeplessness may also be a side effect of over-the-counter products like nasal decongestants and appetite suppressants.

Chronic insomnia usually has different causes, and there may be more than one. These include:

• A medical condition or its treatment, including sleep apnea, arthritis, a heart condition, and asthma.
• Use of such substances as caffeine, alcohol, and nicotine.
• Psychiatric conditions like mood or anxiety disorders.
• Stress or depression, such as sadness caused by the loss of a loved one or a job.
• Disturbed sleep cycles caused by a change in work shift.
• Sleep-disordered breathing, such as snoring.
• Periodic jerky leg movements, nocturnal myoclonus, which happen just as the individual is falling asleep.
• Repeated nightmares or panic attacks during sleep.

Another cause is excessive worrying about whether or not a person will be able to fall asleep, which creates so much anxiety that the individual's bedtime rituals and behavior actually trigger insomnia. This is called psychophysiological insomnia.

Symptoms of insomnia

People who have insomnia do not start the day refreshed from a good night's sleep. They are tired. They may have difficulty falling asleep, and commonly lie in bed tossing and turning for hours. Or the individual may go to sleep without a problem but wakes in the early hours of the morning and is either unable to go back to sleep, or drifts into a restless, unsatisfying sleep. This is a common symptom in the elderly and those suffering from depression. Sometimes sleep patterns are reversed and the individual has difficulty staying awake during the day and takes frequent naps. The sleep at night is fitful and frequently interrupted.

Diagnosis

Insomnia, unlike some medical conditions, is easily recognizable. People know when they aren't getting enough sleep. The key to treating insomnia is determining its causes. Some people can identify sleep-inhibiting factors such as a death in the family or a hectic work schedule with too much caffeine consumption and not enough exercise. A doctor will take factors such as these into account when making a diagnosis.

The physician's diagnosis is based on the patient's reported signs and symptoms. The doctor may review a patient's health history or order tests to determine if a medical condition is causing the insomnia. The physician may ask if the patient is depressed, in pain, under stress, or taking medications, according to the National Sleep Foundation. The doctor may ask about disruptions in a patient's life such as working nontraditional shifts or traveling across different time zones.

It can be useful for the patient to keep a daily record for two weeks of sleep patterns, food intake, use of alcohol, caffeine, nicotine, medications, exercise, and any other information recommended by the physician. If the patient has a bed partner, information can be obtained about whether the patient snores or is restless during sleep. This record, together with a medical history and physical examination, can help confirm the doctor's assessment.

A wide variety of healthcare professionals can recognize and treat insomnia, but when a patient with chronic insomnia does not respond to treatment, or the condition is not adequately explained by the patient's physical, emotional, or mental circumstances, then more extensive testing by a specialist in sleep disorders may be warranted.

Treatment

In both alternative and conventional medicine, treatment of insomnia includes alleviating or coping with any physical and emotional problems that contribute to the condition. Also effective is exploration of changes in lifestyle that will improve the situation.

Changes in behavior

Patients can make changes in their daily routine that are simple and effective in treating insomnia. Eating a healthy diet rich in calcium, magnesium, and the B vitamins is also beneficial. A high protein snack like yogurt before going to bed is recommended.

Patients should go to bed only when sleepy and use the bedroom only for sleep. Activities like reading, watching television, or snacking should take place elsewhere. If people are unable to go to sleep, they should go into another room and do something like reading. People should return to bed only when sleepy. Patients should set the alarm and get up every morning at the same time, no matter how much they have slept, to establish a regular sleepwake pattern. Naps during the day should be avoided, but if absolutely necessary, than a 30-minute nap early in the afternoon may not interfere with sleep at night.

Another successful technique is called sleep-restriction therapy, restricting the time in bed to the actual time spent sleeping. This approach allows a slight sleep debt to build up, which increases the individual's ability to fall asleep and stay asleep. If a patient sleeps five hours a night, the time in bed is limited to 5–5.5 hours. The time in bed is gradually increased in small segments, with the individual rising at the same time each morning; at least 85% of the time in bed must be spent sleeping.

Mind and body relaxation

Incorporating relaxation techniques into bedtime rituals helps a person go to sleep faster and improves the quality of sleep. These, alone or in combination with other relaxation techniques, can safely promote sleepiness. Also effective are massage techniques such as the "cat stroke." The masseuse's hands move gently across the back. Four other types of stress-reducing bodywork were recommended in Spontaneous Healing, the book by Andrew Weil, M.D., who practices natural and preventative medicine. Weil recommended Feldenkrais, which includes movements, floor exercises, and body work; Rolfing, which involves firm pressure; shiatsu, the traditional Japanese form of body work; and Trager work.

Learning to substitute pleasant thoughts for unpleasant ones (imagery training) helps reduce worrying. Another technique is using audiotapes that combine the sounds of nature with soft relaxing music. Meditation, prayer, and breathing exercises can also be effective.

Many alternative treatments are effective in treating both the symptom of insomnia and its underlying causes. Much treatment is centered around herbal remedies. The herbs most often recommended for treating insomnia include reishi mushroom, hops, valerian, skullcap, passion flower, lemon balm, ginseng, St. John's wort, and kava, which is also known as kava kava.

Herbal teas

Some people treat insomnia by sipping a warm cup of tea made with an herb such as chamomile, hops, passionflower, or St. John's wort.

Aromatherapy and hydrotherapy

Aromatherapy involves healing through essential oils, the aromatic extracts of plants. Essential oils may be used for a soothing bath; applied to the face, neck, shoulders, and pillow; or diffused in air.

Hydrotherapy consists of a warm bath, scented with an essence such as rose, lavender, marjoram, or chamomile. In the 1998 book Healing Anxiety with Herbs, Harold Bloomfield, M.D., recommended adding 2-15 drops of 10% essential oils into approximately 100°F (38° C) water. He also recommended using lavender and also suggested using ylang-ylang, neroli (orange blossom), geranium, and patchouli. The bath should be "approached in an unhurried and meditative state," Bloomfield wrote.

Dream pillows

Another form of aromatherapy involves sleeping on a dream pillow. Also known as a sleep pillow, it can be made by sewing together two 8-inch pieces of fabric. There should be an opening wide enough to insert a tablespoon. Herbs such as hops, chamomile, and lavender are spooned into the dream pillow, which is placed under the bed pillow.

Melatonin

Melatonin is a natural hormone that is secreted from the brain's pineal gland. The gland regulates a person's biological clock, particularly day and night cycles. When taken as a 3-mg dose one to two hours before bed for a maximum of four to five days per week, the dietary supplement melatonin is said to be effective in shortening the time before one falls asleep. The hormone can help to avoid jet lag and to establish sleep patterns for shift workers. However, melatonin is not regulated by the FDA, so there are no regulatory controls. Side effects may include mental impairment, drowsiness, severe headaches, and nightmares.

Traditional Chinese medicine

Traditional Chinese medicine (TCM) treatments for insomnia include acupuncture and herbal remedies. Acupuncture involves the insertion of needles to manipulate energy flows around the body. Acupuncture is also applied to the treatment of conditions including anxiety.

In TCM, herbs are used as remedies in teas and other preparations. Treatments for insomnia include reishi, a medicinal mushroom available in extract form.

Light therapy

In light therapy, natural or artificial light is used to boost serotonin, a neurotransmitter in the brain related to reducing anxiety. This therapy is used to treat seasonal affective disorder, a condition that some people experience when there is less sunlight or fewer daylight hours. Bright light therapy can be used for people whose insomnia is caused by jet lag or irregular work shifts. In the morning, the person is exposed to artificial lamps with a brightness of more than 2,000 lux. The treatment continues with avoidance of bright light during the evening.

Allopathic treatment

A physician may determine that drug therapy is necessary to treat insomnia. Drugs may be prescribed if the patient is undergoing a crisis or insomnia persists after a patient has made lifestyle changes. However, drug therapy is regarded as a short-term remedy, not a solution.

Conventional medications given for insomnia include sedatives, tranquilizers, and antianxiety drugs. All require a doctor's prescription and may become habit-forming. They can lose effectiveness over time and can reduce alertness during the day. The medications should be taken up to four times daily or as directed for approximately three to four weeks. This will vary with the physician, patient, and medication. If insomnia is related to depression, then an antidepressant medication may be helpful.

Drugs prescribed for improving sleep are called hypnotics. This category includes benzodiazepines, which are prescribed for anxiety and insomnia. Benzodiazepines most commonly prescribed for insomnia include Dalmane (fluazepam), Halcion (triazolam), Ativan (lorazepam), Xanax (alprazolam), Restoril (tempazepam), and Serax (oxazepam).

Insomnia is such a widespread problem that "people buy more over-the-counter and prescription sleeping medications than any other drug," according to CBS Health Watch. Many over-the-counter drugs have antihistamines as an active ingredient. While these products are not addictive, some experts believe they are not very effective in sustaining stage IV sleep and can affect the quality of sleep.

Over-the-counter sleep products include Nytol, Sleep-Eez, and Sominex. Antihistamines are used in combination with pain relievers in products including Anacin PM, Excedrin PM, Tylenol PM, Unison, and Quiet World.

Expected results

Insomnia has numerous causes and treatments, so the amount of time may vary before results are seen. A prescription drug may bring immediate results to someone coping with a spouse's death. An herbal remedy may not work immediately for a person who consumed excessive amounts of caffeine to stay awake at work after a sleepless night.

There has been research that provides information about when some treatments take effect:

• Melatonin: a dose of 3-5 mg taken within an hour of retiring will normalize sleep within 1-2 weeks.
• A combination of hops and valerian at bedtime can provide a good night's sleep.
• A combination of alternative therapies should bring a difference in disturbed sleep within two to four days.
• Valerian extract may take from two to three weeks before "significant benefits" are seen.
• St. John's wort can take two weeks to take effect.
• Combinations of treatments could more quickly bring about an uninterrupted night of sleep. The person who reduces caffeine intake, walks for 15 minutes and enjoys an herbal bath may discover that that combination brings restful sleep.
• Acupuncture: "A state of deep relaxation is often an immediate benefit of treatment for chronically anxious patients," William Collinge wrote in The American Holistic Health Association Complete Guide to Alternative Medicine. In addition, positive results were recorded in a study of people who had trouble falling asleep or remaining asleep, according to the an article in the October 1999 issue of the Alternative Medicine Newsletter. Patients received acupuncture for three to five sessions at weekly intervals. While acupuncture appeared effective, a "directive influence by the therapist cannot be excluded," according to the article.
• Light therapy usually results in earlier bedtimes.

Prevention

Prevention of insomnia centers around promotion of a healthy lifestyle. A balance of rest, recreation, and exercise in combination with stress management, regular physical examinations, and a healthy diet can do much to reduce the risk.

Walking is also recommended. However, exercise should be done no more than three hours before bedtime.

Drinks that contain caffeine such as coffee, tea and colas, chocolate (which contains a stimulant), and alcohol, which initially makes a person sleepy but a few hours later can have the opposite effect should all be avoided.

Maintaining a comfortable bedroom temperature, reducing noise, and eliminating light are also helpful.

Watching television should be avoided because it has an arousing effect. Weil wrote that the news with its "murder, mayhem, and misery" is a major source of turmoil. He sometimes advises "news fasts" as part of a healing program.

Exercise, relaxation, and nutrition should be considered ongoing preventive measures. While life will bring unexpected stresses and pressures, the person who is familiar with relaxation techniques will be more prepared to cope with insomnia.

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