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See also:  "Sleep:  Difference is Day and Night"

Why We Can’t Sleep and What We Can Do About It



Dennis B. Kottler, MD



This is the second part in a series looking at major health concerns that affect our society in epidemic proportions.  This current monograph deals with the epidemic of insomnia and offers practical suggestions to combat this major health threat.  Innovative self-treatment approaches are discussed that have proven effective in large numbers of people.  The author also addresses impediments to sleep that involve relationships with other people and personal psychological “roadblocks.”  It is hoped that many individuals with insomnia will find this monograph of major help in finally putting their sleep disorder to bed.


Insomnia Defined

The DSM IV (Diagnostic and Statistical Manual of Mental Disorders – 4th ed.  p. 553) states that:

“The essential feature of primary Insomnia is a complaint of difficulty initiating or maintaining sleep or of non-restorative sleep that lasts for at least one month and causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.  The disturbance in sleep does not occur exclusively during the course of another sleep disorder or mental disorder and is not due to the direct physiological effects of a substance or a general medical condition.”


In primary insomnia, the focus of this monograph, the sleep disturbance is caused by problems involving the sleep/wake mechanism, with environment, lifestyle, and self-conditioning, as well as genetic predisposition, frequently playing causative roles. 

There are different patterns of insomnia, although many people suffer from a mix of all of the following:


Initial insomnia   -  Difficulty falling asleep

Middle insomnia   -  Difficulty staying asleep

Terminal insomnia   -  Awakening earlier than desired (not terminal in the morbid sense)


It is nearly impossible to estimate the prevalence of insomnia in the general population, although we do know it is an extremely common complaint and endless people approach their physicians for relief, often requesting sleep medication (more on this later). 

Although this monograph focuses on self-help, it is suggested that those, hopefully few, individuals who do not obtain relief from their insomnia after following the suggestions in this monograph consider medical consultation.


The Cost of Insomnia

The damage done by insomnia in markedly decreased quality of life, lost productivity, and contribution to other health problems is enormous and virtually impossible to estimate.  From the individual standpoint, the sufferer is often driven to a point of desperation, willing to try any solution, again most frequently in the form of a prescription or nonprescription drug, or “alternative” drug remedy. 


Variations in Sleep Patterns   (What is the “Normal” Amount of Sleep?) 

The discussion of “normal” is problematic for many physical and behavioral conditions.  For example is 5 feet 2 inches tall a normal male height?    Can it be normal for a male to be balding at 25 years old?    Similarly, is an average of 5 or 6 hours of sleep normal. 

It is increasingly recognized that there are wide variations in “normal” sleep requirements among individuals.   Much of this variation is no doubt genetic.  Some people are “short

sleepers” and others are “long sleepers.”  An average duration of good, solid sleep of 7 to 9 hours is generally looked upon as a norm.  However, some individuals report needing only 5 to 6 hours and at the other end of the spectrum, some individuals seem to require 10 hours.  If these sleep ranges produce satisfactory results in a given individual without complaints of daytime fatigue, irritability, diminished concentration, depression, or excessive worry and anxiety, than they are probably “normal” variations.   Otherwise, one must consider these as abnormal states requiring further diagnosis and treatment.  Certainly, if these sleep variations are such that they produce disruption in one’s usual occupational or social functioning, they should become areas for further investigation and possible treatment.

Aside from duration of sleep, there is also variation in how soundly individuals sleep.  Again there are probably genetic factors at work.  Some people describe themselves as having been light sleepers their whole lives.  One female patient complained that almost anything can wake her up,   “If the proverbial pin drops…I wake up.”  What aggravated her, she said, was that her husband slept “like a log.”  “Nothing wakes him up.”  She describes that her husband slept through a 6.3 magnitude earthquake resulting in significant structural damage to their home.  Even things in the bedroom had fallen to the floor, including one ceramic statue that was shattered when it fell.  Finally, the only thing that awakened her husband was her screaming.  She went on to say that when it was all over she asked her husband how he could possibly have slept through all this.   He said he had no explanation, except he did report that the night of the earthquake, he had a dream about his parents fighting when he was a little boy and in the dream he had images of his mother throwing plates at his father.  Apparently he had incorporated the sound of the crashing objects in the room into the dream.   This man is one lucky sleeper, although perhaps also the kind of person who could perish in his sleep.  Everything has its upsides and downsides.

The light sleeper may go through life reasonably well, and even survive situations because of the ability to awaken, in time.   However, the downside is the tendency of light sleepers to be more prone to becoming insomniacs.  Conversely, the deep sleeper probably has some genetic advantage affording a relative protection against this disorder.  Nonetheless, as people age, insomnia becomes more common, and the deep sleeper of age 30 can evolve into the insomniac at age 50  or 60.    Theories for this change involve biological processes, wherein it is thought that the sleep mechanism of the brainstem becomes less reliable with age, as well as mental change with increased susceptibility to be distracted by worry.   Furthermore, as one ages, there is often just that much more to worry about.  The snowball keeps growing larger and larger. 

Although the focus of this monograph is on insomnia, it should be mentioned that it is possible to sleep excessively and this condition, hypersomnia, can also lead to significant disruptions in one’s life.  Another condition, narcolepsy, results in paroxysmal episodes of sleep during the day and has other accompanying symptoms as well.  These conditions are best left to a professional to diagnose and treat.


One Last Tangent

As you may remember from the excerpt quoted above (from the Diagnostic and Statistical Manual of Mental Disorders – 4th ed.  p. 553) regarding primary insomnia:

“The disturbance in sleep does not occur exclusively during the course of another sleep disorder or mental disorder and is not due to the direct physiological effects of a substance or a general medical condition.”


This cannot be over-emphasized.  It is extremely important to ascertain that the sleep problem is in fact not a result of some other mental or physical condition, including drug use, in which case there may be a specific treatment approach that may resolve the problem.   Appropriate professional consultation is the only way to be sure of this. 

A few examples of physical disorders presenting as sleep disturbances are hyperthyroidism, back problems, and anything causing physical pain.   Examples of  psychiatric disorders which may result in sleep disturbances are mood disorders, generalized anxiety disorder, panic attack disorder, psychotic disorders, and somatic preoccupation disorders.  Substance use problems include excessive caffeine use (varies by individual) especially later in the day, alcohol, and the various “recreational” drugs.  Also, a large number of prescribed medications have sleep disorder side effects.   This category includes some antidepressants (can also help with sleep in some cases), stimulating antihistamines, and potentially a great number of other medications.  See a more complete listing of other causes of sleep disturbance under the heading, “Psychiatric/ Physical Impediments to Sleep.”

Finally, there are still other specific sleep disorders which result in lack of restful and sustained sleep that have specific causes and are therefore viewed as distinct from primary insomnia.   These disorders include breathing-related sleep disorder (various apneas), circadian rhythm sleep disorder (shift work and time zone changes), and parasomnias (example:  sleep walking).   Again, a professional is required to rule out and treat these specific conditions.

It is also important to remember that true primary insomnia by definition lasts for at least one month and frequently becomes recurring or chronic.  Transient insomnia often occurs in response to a particular disturbing event or focus of attention but it is not sustained and sleep soon returns to normal.  


Common Characteristics of  Insomnia (We’re Getting Close to the Payoff)

Many of the characteristics of primary insomnia also suggest possible treatment approaches.   For example, insomnia is often initially triggered by some troubling event or physical injury and then becomes an established pattern lasting long after the initial stimulus is resolved.   The person begins to anticipate that each night will be a repeat of the last.  However, in many cases there is no obvious precipitant to the insomnia. 

Whether there is a precipitant or not, the individual becomes “conditioned” to the difficulty sleeping.  The bed may come to represent a negative place, associated with tossing and turning and frustration.   Nighttime, itself, becomes dreaded for the same reasons.   The individual may even avoid going up to bed at all, preferring to stay up and watch television to avoid the whole problem; of course that is the problem. 

In the opposite situation, the person attempts to confront the sleep problem head on, full force ahead.   He gets into bed and tries and tries to sleep.  He tries really hard.  He is constantly checking the time on the clock.  The race is on to fall asleep while there is still enough time left in the night to get enough sleep.  But as in most such feats of great effort, the anxiety level rises and the adrenaline gets pumping.    This is fine in a real race or perhaps in some other performance-oriented task.   However sleep requires just the opposite conditions.  Sleep must be a surrender to passivity.  The individual must allow it to happen…it cannot be willed or achieved by brute force.  It is the result of a relaxed state, free of physical and mental stimulation. 


Ok, So You Have Insomnia, Now What?

Certain specific principles, if followed carefully, will in most cases of primary insomnia result in the re-establishment of a satisfactory sleep pattern.   I will list and discuss each of these principles:


1.    Set a consistent time to go to bed and to wake up:

Treat yourself as well as you treat your children or as you were treated as a child.   “Too much freedom can be a very disrupting thing.”  The brain’s internal clock (circadian rhythm device in the brainstem) runs best without interference.  It awakens the body, normally with the early morning light, and induces sleep as the sun goes down.  

However, technology has modified this normal sleep/wake schedule dramatically with the advent of artificial light. The electric light bulb allows us to be active far beyond the bedtimes that were observed for the million years previously.   This latter fact probably has more to do with insomnia than anything else.  We feel that, since we have light available, we might as well work a little later, party a little later, or just plain stare at the light bulb itself (TV?).  Soon we are pushing our bedtime later and later and creating circadian rhythm shifts…and insomnia.  So set a consistent bedtime and try to stick to it!  An try to make this bedtime and “arise” time reasonably correspond to the natural daylight.  (Ok, I’ll let you stay up a few hours after dark).

(This is skippable but you may be interested to know:  Theory has it that bright light, as in the morning, triggers a neural pathway starting in the retinas of the eyes and ending in the pineal gland.  The final effect of the bright light exposure is to suppress the production of melatonin, thought to be produced by the pineal gland.  For many years we had no idea what this small pea-shaped structure did.  It seems the melatonin is a sleep inducing substance and its suppression allows the body to wake up.   This starts the “awake part” of the circadian cycle.   Before the light bulb, the dimming of light into nightfall would gradually lead to the unsuppression of melatonin from the pineal and sleep would ensue.  Whether melatonin taken in pill form has the same effect is debatable, since it has to go through the digestive system and then cross the blood-brain barrier.    Anyway, many have tried it with mixed results).


2.    Develop a consistent sleep “routine.” 

Treat yourself again as well as a child is treated.   It is no coincidence that in a great many societies there is some form of ritual to help children fall asleep.  In our society it often involves reading a bedtime story with a parent (or at least we used to do this) or watching that last television show, brushing the teeth, kissing the dog goodnight (maybe the other way around), getting into bed, a good night kiss from mommy, tucking the covers around the feet, and falling asleep.    I bet you’re tired just reading this last sentence.   Anyway you get the idea.  Find some reasonably adult-feeling routine to do consistently each night.  It might incorporate such useful rituals as locking the doors and windows, laying out the clothes for tomorrow, grinding the coffee for the morning, brushing the teeth, getting into bed, a good night kiss from somebody (?), tucking the covers around the feet, and falling asleep.   Believe me these things help.

(This is skippable but you may be interested to know:   Tucking the covers around the feet may have a specific sleep-inducing value beyond the ritual value.  There have been studies showing that warming the feet actually is associated with inducing sleep and some have recommended heavy socks, for example, to achieve this.  Perhaps warming the feet dilates vessels in the skin and redirects blood flow to the extremities, a technique often used in “relaxation exercises” (an oxymoron).  


3.   Under no circumstances become a “Clock Watcher.”

This is bad, bad.   If you do awaken during the night, and it happens, sometimes several times a night even in people without sleep problems, do not look at the clock.  Clock watching only increases the anxiety level and feeds the dread that, “I’m not asleep, it’s already 4 am, and in three more hours I’ll have to meet with my boss and I’ll sound like a total moron.  And now I’m so worried about this that I can’t sleep.”  Please place that unpleasant intrusion of modern civilization someplace where it won’t be noticed until the alarm finally goes off. 


4.   Limit time in bed to time actually spent sleeping.

This idea may sound counterintuitive at first, but it has a lot of value.   Many people try to make up for their chronic lack of sleep by going to bed earlier and earlier, or sleeping later in the morning.  Generally this is a bad approach.  One ends up with a longer period in bed experiencing fragmented sleep, marked by short periods of sleep interspersed with fits of wakefulness.  Also sleeping later in the morning on a regular basis seems to frequently invite other problems.  The person often wakes up tired, even though he apparently “slept” until 10 or 11 am. 

This makes it hard to “get going” most of the day, for many people, until the nighttime when they wake up again.  In effect, one is shifting the sleep cycle, often later and later.  And it does seem to matter when one sleeps.  The sleep cycle functions best when it can be coordinated with the natural cycle of daylight and nightfall.  As explained above in item #1, light triggers the circadian clock and keeps the sleep/wake cycle functioning properly.  Of course if one does night work, this coordination of sleep with daylight is problematic and one has to attempt to create “artificial” night and then wake up to bright artificial sunrise, to get the brain working properly. 

The recommended approach for the insomniac is to restrict time in bed for several weeks, to the time actually spent in sleep.  This may require the person stay up later and maybe get up earlier.   This will result in defragmenting the sleep pattern and consolidating the actual time spent sleeping.  (A useful image for computer buffs:  Imagine defragmenting the hard drive by consolidating all those little file fragments into one continuous storage space, the machine runs a lot better).   Going to sleep later may cause some initial additional sleep deprivation, but the individual will begin to experience a much better quality of sleep and less interrupted sleep.  Of course if one cannot get to sleep until 3 am and awakens at 10 am, the sleep restriction might have to come off the morning end of things.


5.   As much as possible confine bedtime activities to sleeping

This advice in general helps in combination with everything else discussed.  Reserve the bed for sleep and sex, assuming this latter activity is somewhat sleep-inducing.  This is not a firm “rule” and if it helps to fall asleep by reading in bed, especially a heavy, hardback book (don’t drop it on your face) or one that is somewhat boring, by all means continue to do so.  Other activities like eating, chewing gum, playing the guitar, and fighting with your spouse, are best done somewhere else and not when trying to sleep.  


6.   Develop a system to track and deal with worries during the day.

Many people find it helpful to go over the problems of the day, each day, well in advance of bedtime, and perhaps create a list of problems and courses of action.  The course of action need not be a solution, some problems are not readily soluble.  It could just be a step that will be taken the next day or a decision to table the matter until another time.  At any rate, each issue should have some “disposition” made, and then forget about it until the morning.   When the “notebook” closes on this problem list, it is out of mind.  Leave the problems in the notebook.


7.   Get exposure to early morning, bright light.

This is a helpful suggestion for everyone.  The bright morning light is helpful in sustaining and, if necessary, restarting the normal sleep/wake cycle.  Have the morning coffee (if you must) or cereal on the patio.  Or begin the day with a nice walk in the morning light, a short walk is adequate.   If morning light is not available (shift workers) try to create the same effect with bright light in the house…commercial light boxes are actually sold for this purpose.  


8.   Avoid bright light prior to bedtime.

A corollary to the item above is the avoidance of bright light in the evening.  Some people are particularly sensitive to the sleep disturbing effects of such light.  Remember, light turns off the melatonin release from the pineal and this triggers the awake state.


9.   Devise a plan with your physician to eliminate hypnotic drug use.

If at all possible, and it almost always is, work out a plan with your physician to taper off hypnotic drugs, prescription and non-prescription alike.   These medications are like laxatives.  After awhile you can’t go without them.   The downside is that eventually they lose their effectiveness, especially the prescription drugs, and you are seduced into ever higher dosages.   The non-prescription sleep aids generally incorporate diphenhydramine (Benedryl) which is all right to use at times, but generally is very drying and can leave one with a fuzzy feeling in the morning.   Some of these sleep aids combine diphenhydramine and acetaminophen (Tylenol) which exposes the person to gratuitous acetaminophen, a potential liver toxin if taken in significant quantities over a period of time.


10.   Avoid daytime napping

This is intuitive.  Sleep during the day, pay at night.  Or don’t complain about not sleeping, since if you add up all the naps, you didn’t do so badly after all.  Yet most nappers aggravate about being “unable to sleep.”  They are sleep experts, just at the wrong time. 


11.   Include any bed partners in the treatment plan.

Again, this should be obvious.  If it is not, read the examples below, in the next section, about how a bed partner can sabotage your sleep.  Even if sabotage is not the problem, the emotional support and encouragement of a friend, spouse, or whatever, is always helpful. 


12.   If still not sleeping well, consider the suggestions below in, “When Nothing Else Works.”


External Environment:  Aids/Impediments to Sleep

Some of these environmental aids and impediments are obvious and some are more subtle.   In solving the sleep problem rigid rules often do not work; the trick is identifying what works for a given individual and staying with it.  Thus a radio in the background may do wonders for some people and be a total distraction for others.  Generally anything too stimulating, for example an interesting talk show, is counterproductive to sleep since it tends to engage the mind too much.  On the other hand, soft music (preferably nice and monotonous without commercial interruption) or white sound, such as soft static between radio stations or that produced by any of various “sleep machines” is helpful.  Such nonverbal, soothing, background noise interferes with the ability to have an internal dialog in the mind, but yet is low-keyed enough not to pose a disruption to sleep.  

Regarding light, the conventional wisdom is lights off.  However some individuals may be conditioned positively, perhaps from childhood, to sleep with a night light on.   If it works, do it.   Of course, all these matters have to be negotiated with a sleep partner if there is one.

Hard beds, soft beds, one pillow or seven, prone or supine position, whatever works, works.  Some people seem to fall asleep if they put a pillow between their knees.  Others find that warming their feet with heavy socks helps.  As discussed above, there have been several articles recently regarding feet warming and sleep, suggesting that this soporific effect may have some physiological basis!

What about other people?  Many individuals do not sleep alone.   This can be both an aid and a hindrance.  Some find comfort in the close physical contact of the sleep partner. This may be a person, but it may equally well be a dog, real or stuffed.  I knew of one man who slept with a blow up doll, and it was a perfectly platonic relationship, he assured me.  Yet it helped him sleep.   It only created a problem when his morbidly obese wife rolled over onto the doll and destroyed it beyond repair.   The man was furious and accused his wife of doing this on purpose, out of  jealousy.    This is not a joke.  Whatever works, works.

There is an interesting phenomenon of induced sleep disorder.  One person complained that she always slept well until several years into her marriage.  It turns out that this individual’s spouse seemed to need very little sleep, sometimes only 5 or 6 hours a night.  The person who previously had no sleep problem, starting staying up late to keep her spouse company and because she did not wish to go to sleep alone.  After a period of time she started feeling exhausted during the day, but she persisted in depriving herself of sleep.  This continued for many months and the woman had in fact developed a form of insomnia by example.  However, one might argue it was not true insomnia, since once this person recognized the pattern of sleep deprivation and decided to do something about it she had little trouble returning to her usual sleep habits.   Curiously, she did get a divorce a few years later, nothing to do with the sleep issue, she insists (?).


Internal Environment:  Aids/Impediments to Sleep

Some people fall asleep quite well if they direct their thoughts, while in bed, to certain subjects.  Some find this works much better than thinking about the tranquil beach scene.  One patient told me she hates the beach and thinking about the beach aggravated her.    But being compliant, she attempted to use this image, not wanting to hurt the feelings of the therapist who had suggested it.  She also thought that, “look I’m paying this person $$$ to help me, she must know what she is doing.”  A better therapeutic approach would have been for the therapist to have the patient come up with images that are pleasing and then encourage her to use these.   There is no canned approach here.  What works, works. 

Another individual, who has an interest in mechanical things, found that trying to design an alternative to the internal combustion engine while in bed inevitably resulted in sleep.   Quite conveniently the engine problem never got resolved so it was always available to ponder the next time.  In fact, he had so conditioned himself around this particular thought content that just starting to think about it would result in sleep, sometimes in a few minutes.  Extending this concept, ask yourself what are interested things to think about that would not be too frustrating or disturbing.    There is no formula, since one person’s pleasant thoughts are another person’s “nightmare.”  Generally, thought content that helps is directed along the personal interests of the individual.    Mathematicians may find it helpful to ponder math problems; others would try this and get up screaming, or perhaps just be bored enough that they fall asleep.  Try out various different sleep-thoughts.  And if you have come upon something that produces results use it.   If the mind starts aggravating itself over some worry, trivial or not so trivial, and sleep is impossible, change the internal channel, use the sleep-thought.  Whatever works, works.


Psychological Impediments to Sleep

Some of the more insidious, but nonetheless powerful impediments to sleep, involve internal, psychological conflicts.  It is sometimes possible to discover these oneself by self-reflection.   Perhaps some insomniac readers will relate to one or more of the situations described in this section.

Strange as it may seem, but the human mind is strange after all, some of the people who so desperately wish to sleep are actually resisting sleep, usually on an unconscious level.  One example of this concerns the individual who has a morbid fear of sleep.  Such a person may associate sleep with death:  “If  I fall asleep, I may never wake up again.”  Again this fear may not be fully conscious.  This particular fear might occur, for example, in someone who fears a heart attack in his sleep; perhaps this happened to a friend or parent.  Perhaps there are other less obvious reasons for this fear to develop related to childhood.  

In another case, of a fully conscious sleep avoidance, the problem might be one of not wanting to go to bed.  In this case, a person may dread the sexual advances of a spouse (or other partner) and will stay outside the bedroom, watching television, perhaps, until the other person is soundly asleep.  If the sleep partner happens to be an insomniac, the wait could be quite lengthy and set up the sexual avoider for a case of conditioned sleep disturbance. 

In a different scenario, the problem might not involve avoiding sleep so much, as not wanting to give up the night (different emphasis but the same effect).  Some people pride themselves on being “creatures of the night.”  They may boast about how little sleep they (think) they need.  This may verge on “macho” pride.  A variant of this is the individual who savors the late night hours.   This person feels most comfortable when everyone else is asleep and he can have “peace.”   There are no ringing telephones, salesmen at the door, or demanding children (or spouses).  In fact, it feels to this night bird that he is the only one awake on the entire earth.   Sometimes the night might be a haven for the asocial, other times it is a very welcome relief from the distractions of the day.   It is a time to relax without intrusion or to get some work done.  The inevitable consequences of this lifestyle are daytime fatigue (many times denied) and often increasing “sleep debt” with symptoms of irritability, depression, low energy, and sometimes even aggressive behavior.  Such people often become aware of their increasing sleep problem and periodically resolve to “get to bed earlier” but they keep slipping back into the old pattern. 

Another form of psychological impediment to sleep involves certain personality traits, which may actually interfere with going to sleep.  Such an individual might be strongly anti-authoritarian and defy rules even though to do so is clearly self-destructive.  This individual might insist on not wearing a seat belt, because “no one is going to tell me what I have to do in my own car.”  Similarly, the whole concept of a “bedtime” might be reprehensible to this person.   This individual avoids rules, and a consistent “bedtime,” because any such routine feels like “someone is telling me what I have to do.”  Again this problem may not be fully conscious.  A clue to its existence did occur in one case I remember when a concerned wife kindly suggested to her “up all night” husband that it would be a good idea to get to bed (it was 3:00am).  The loud retort came back from the computer room where he was cyber-surfing:   “No one tells me what to do, not you, my mother, or anyone else, understand.”   The humbled wife back-pedaled,  “Ok.  Ok.  I was only trying to help.” 

Another personality impediment to sleep involves the obsessive-compulsive person and sometimes also, the “type A” person.  In either case, and these disorders can coexist, the individual does not want to give up what he is doing and go to sleep.  He is continually busy, always having to do “one more thing,” sometimes stretching out to 3 or 4 am.  There is sometimes a compulsive rigidity that seems to drive this individual.  There are sometimes also fears that “if I don’t get this done now I will forget what I have to do.”  Curiously the activity might just as well involve something trivial as something important.  The pattern is not rational, and certainly the sleep deprivation the next day cancels out any productivity gains made the night before, but we already agreed the mind often works in mysterious ways. 

These are but a few examples of psychological impediments to sleep and I am sure there are numerous more.  Some serious self-reflection might be in order and than an all out attempt to defeat the “demon” within (excuse the dramatics).  


Psychiatric/ Physical Impediments to Sleep

There are of course many psychiatric and physical conditions which have as one of their symptoms sleep disturbance.  This subject was touched on above in “One Last Tangent.”  In these cases the primary psychiatric/physical condition should be treated first and hopefully the sleep disturbance will resolve.  Of course, professional medical attention will be required.   It is also of course possible to have a primary insomnia coexist with a diagnosed psychiatric or medical condition.  These conditions include the following (there are many others):



Psychiatric Conditions Interfering with Sleep:


Major Depression

Bipolar Disorder

Generalized Anxiety Disorder

Panic Disorder

Posttraumatic Stress Disorder


Obsessive-Compulsive Disorder

Toxic Metabolic States




Physical Conditions Interfering with Sleep:



Back Pain (Sometimes worse at night)

Various Breathing Disorders (e.g. Obstructive Apnea)

Sinus Pain (Often worse at night in the supine position)

Headaches of various types – tension, cluster, migraine

Moderate to Severe Pain of any kind

Tumors of the Brainstem (very rare)

Pheochromocytoma  (a very rare tumor of the adrenal gland)



“Substances” Interfering with Sleep:


Excessive Caffeine Intake (especially towards evening)

Chocolate (contains stimulants, especially if  “natural” chocolate)

Cocoa (contains stimulants)

Various Natural Remedies (e.g. St. John’s Wart)



Stimulants such as Cocaine



Pharmaceuticals– both prescribed and over the counter:


Ritalin (especially if taken late in day or evening)

Dextroamphetamine (especially if taken late in day or evening)

Antidepressants (e.g. Prozac, Zoloft – also often sedating)

Antihistamines (especially if have caffeine or pseudoephedrine)

Opiates/Opioid drugs (Vicodin, Loricet ) – sleep inducing but disrupt normal patterns


This list is very incomplete, and any of a number of medications/substances could be a factor in insomnia.  Furthermore, a medication that may generally be sedating or neutral may cause insomnia in a particular individual.

Finally, withdrawal effects from any of a number of medications/substances can initiate insomnia.  This is true of sedative medications, some antidepressants in my experience, barbiturates, and certainly alcohol.  

In general, if one experiences insomnia (or excessive sleep for that matter) and is taking a substance or medication, prescribed or over the counter, it is a good idea to try to eliminate this first as a cause of the sleep disturbance.  Consultation with a pharmacist or physician may be necessary.  Do not stop the drug without prior professional consultation.


When Nothing Else Works

There no doubt some diehard non-sleepers for whom applying all the ideas in this monograph do not produce restful sleep.  Sometimes consciously or unconsciously (for various idiosyncratic reasons, some of which are described above) these people are unwilling to follow the principles outlined.  They may even have plunked down the money for the monograph, or attended a self-help workshop, or even attended individual counseling.   For these individuals I offer the following potpourri of ideas. 

Hypnosis – Sometimes learning hypnosis, which actually teaches you to hypnotize yourself, can be the solution to the insomnia.  Often this works by teaching a person how to relax and how to block out everything else.  

Biofeedback -   This technique utilizes various electronic devices to detect physiological responses to stress/anxiety and to give audible/visual feedback which the person can use to learn  relaxation.  Often the biofeedback therapist gives various exercises, physical as well as mental, to aid in relaxation and sleep induction.

Drugs – Not my first choice, but medications often work when all else fails and can be useful as a temporary means to break the abnormal sleep pattern.  The shorter acting medications, such as Restoril (intermediate), Ambien (intermediate to short), Halcion (short acting), and Sonata (very short acting) are generally preferable to the older, longer acting medications, such as Dalmane, which often resulted in daytime sedation.  If the problem is initial insomnia (getting to sleep) the very short acting medications are often best.  However if one awakens during the night, an intermediate acting drug might be preferable.  These are only temporary adjuncts to the behavioral approaches suggested above.

Warm Milk, Warm Feet (see above), and Reassurance.



I have attempted to provide an overview of the insomnia problem, as it is experienced in its many forms, by vast numbers of people in our society.  In addition, I have offered what I believe to be practical suggestions that can be applied to the individual who wishes to finally put this problem to rest, so to speak.  It is my hope that the reader of this monograph will look back in 3 or 4 weeks or so and feel that the time and expense involved was well worth it and that I may have contributed in some small measure to an improved quality of life.   Future monographs will be forthcoming and will address a range of common health problems.


Dennis B. Kottler, MD

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