When patients come in seeking relief from chronic insomnia, unfortunately immediate relief can be rare. Chronic sleep issues tend to be quite complex and are frequently stubborn in turning around, often requiring some careful detective work. Despite this, there is light at the end of the tunnel! If you and your practitioner can work together to ferret out the main underlying cause (or causes), together you can set a path that should move you toward significantly improved sleep. I always tell my patients while they shouldn’t rule out sudden miracles, not to expect them; regaining deep and restful sleep is typically a journey rather than a permanent destination. However, the vast majority of people will see solid and much welcomed change over time.
In this article I’m not going to get into some of the more typical recommendations for sleep, such as making sure your room is dark, not watching screens before bed, making sure your phone is in airplane mode, etc. Most people are well aware of these tips, which are also readily available with a quick internet search. Instead, here are seven of the most common causes of stubborn insomnia that may be less well known. Each issue contains its own particular solution or solutions.
1) Chronic stress. This is probably the biggest cause of insomnia, and is not a surprise for many. A study from the American Psychological Society in 2013 found that “half of all millennials are so stressed out that they can’t sleep at night, and 39 percent of millennials have stress levels that have increased in the past year”. Most are aware that chronic and deep seated stress and even stressful habits (such as those who are workaholics, who just don’t take the time to intentionally incorporate some relaxation or calm moments into their day) will typically wreak havoc on sleep over time. However, I wanted to explain the very real physiological damage that occurs with long term stress, which often helps people to be more motivated in making lifestyle changes.
When you are stressed, your adrenal glands produce two hormones called cortisol and adrenaline to help you cope with the stress. I’m not going to discuss the downside of the excess production of adrenaline at this time (which is more associated with headaches, anxiety and panic attacks), but you should be aware of the very real negative long-term effects that excess cortisol has in your body. We see the side effects in patients on a daily basis.
Not only does cortisol raise your blood pressure and blood sugar, shunt your circulation out of your digestive organs and into your muscles (so you can “run from the bear”), and suppress the immune system, but cortisol acts on your central nervous system by changing the electrical activity in the limbic and hippocampus (important areas of the brain that regulate our emotions, memory, and sleep). This can not only decrease REM sleep and increase time awake, but it can lead to mood swings and memory loss. Long-term accumulated effects of excess cortisol production thus include elevated blood pressure, insulin resistance and problems regulating blood sugar leading to chronic weight gain and possibly diabetes, digestive disorders of all kinds, immune system challenges, mood disorders, and chronic insomnia.
It’s doubly unfortunate that most people who are chronically stressed and tired from lack of sleep, will typically reach for the caffeine, sugar and alcohol on a regular basis. Caffeine, alcohol and sugar significantly weaken your adrenal glands, creating a “catch-22” over time, and after a number of years lead directly to a state of adrenal exhaustion. This is a dangerous state that can require a great deal of time to recover from, and indeed, there are those who never fully recover and live chronically in states of semi exhaustion and fatigue. In this condition, chronic inflammation can become the norm, with painful muscles and joints, autoimmune illness, and other degenerative disease conditions taking over.
Solution: SLOW DOWN, adopt lifestyle habits that work relaxation, calm and “smelling the roses” into your day, and drastically limit or ideally cut out caffeine, sugar and alcohol. There is just no way around it, if you want to live an optimal life, free of pain, illness, and poor sleep.
2) Low Blood Sugar. As I stated above, blood sugar can be significantly affected by stress levels. You can “crash” after a period of stress in exactly the same way you crash after too much coffee. However, unrelated to stress, many people also have genetically determined hypoglycemia that is unrelated to stress, a condition that results when blood sugar levels drop below a certain level. This causes a variety of symptoms including clumsiness, difficulty talking, confusion, feelings of hunger, sweating, weakness and shaking. In extreme cases, a person may experience loss of consciousness, seizures, or death--and this is precisely why the body takes this state very seriously. If you are someone who is hypoglycemic, you will typically not be able to miss a meal easily, and may often carry snacks with you throughout the day. You will already have discovered that fasting isn’t for you. I believe “hangry” is now a dictionary term, which perfectly describes this condition!
But how does this affect sleep? People who are hypoglycemic may experience a sudden drop in blood sugar in the middle of the night--especially if they ate a number of hours before they slept. This will cause their body to go into a state of panic, and wake them up--the body’s way of prompting them to eat. This is a typical pattern in those who fall asleep just fine, but then wake up suddenly in the night--and yet aren’t particularly stressed.
Solution: People with this condition can either make sure they eat a high fat and/or protein snack before bed, or keep a snack by their bed at night and eat a little if they wake up.
3) Hormones. In many women, hormones are a huge contributor to sleep quality. Many women will tell you that they stop sleeping well a week before they get their period. It is even more common for women in their mid to late forties (and sometimes even sooner) who are hitting perimenopause to start experiencing poor quality sleep. During this time as egg quality and quantity start to diminish, many women will start to experience annovulatory cycles, or cycles when they are not ovulating. This causes a drop in progesterone levels especially during the second half, or luteal phase, which can cause cyclic problems with sleep. Women may have several months where they don’t sleep well, followed by some months when they are better. In some women, the insomnia can become quite severe during this time. It can also continue and even worsen as women transition into full-blown menopause.
Solution: Fortunately, there are a variety of solutions that women can try that can work quite effectively. There are some excellent Chinese and Western herbal formulas that I have used on many women successfully to improve poor sleep related to hormonal changes. This includes younger women who typically have sleep troubles during their premenstrual phase. If the herbs still are not working, I will often refer to a biohormone specialist, who can then help her come up with a delivery system for estrogen and progesterone that she can use during her transition phase, which can take a number of years. OTC progesterone cream is also an option for some women, but should only be taken if a woman is still getting a period during the luteal phase (second half) of the cycle. It is always much better to work together with a qualified professional than attempt biohormone replacement therapies alone.
4) Urinating in the night. This can be an issue particularly for older patients, but occasionally can be seen in younger patients as well. Many people will wake to urinate and then quickly go back to sleep. While this isn’t ideal--because it is obviously more restful for your body to sleep through the night--it can be fine for many years. However, there are those who wake to urinate, and then frequently either take a long time to get back to sleep, or never get back to sleep at all. In this case, some experimentation needs to be done to try and figure out how to reduce the nightly urination.
Solutions: This condition can be tricky and in some cases just too challenging to treat. The obvious immediate experiment to try is limiting all fluids after 5pm, or at least 4-5 hours before bed. It typically takes 2-3 hours for a liter of water to be excreted through the bladder. Typically people have already discovered this solution for themselves if it works.
In older people typically age 70 and up, there is a Chinese medical condition called Kidney Yang Deficiency which can cause nighttime urination. This is actually a worsening of the kidney function due to advanced age, which then affects the hormone aldosterone, which plays a role in the retention of salt and water in the body. In this case there should be other symptoms present to corroborate the diagnosis, such as a tendency to feel cold, chronic weakness and soreness in the low back and knees, and sometimes diarrhea and very loose stools in the early morning or upon rising. If this is the case, then Chinese herbal formulas that address Kidney Yang Deficiency can help.
Especially in women after childbirth, the ligaments holding the bladder in place, and in the general pelvic region can become weak, and even in extreme cases prolapse with time. This can cause varying levels of incontinence or trouble holding the bladder. In this situation, I will usually recommend something called pelvic physical therapy, which provides exercises that strengthen these ligaments and help to regain stronger function. We do also have Chinese herbal formulas that work well to support recovery from prolapsed organs.
Finally, urinating in the night can be a critical red flag for sleep apnea, a condition where a person can stop breathing as often as several times a minute during the night. Just as plummeting blood sugar sets off the body’s panic alarm, so does sleep apnea. A common response to panic for the body is the sudden strong urge to urinate. (People with sleep apnea commonly also snore, but not always.) I almost always refer people who I suspect may have sleep apnea to a doctor or specialist for diagnosis and treatment. Sleep apnea is a serious condition with long term detrimental side effects. To read more about it, check out my article here.
5) Sleep apnea. I already discussed this above, but I wanted to include it in its own category.
6) Histamine Intolerance. This condition is less well known, but can be an important primary or contributing cause of insomnia in susceptible individuals. Most of us are familiar with the word “histamine” because of our familiarity with a number of medications that are “antihistamines”, or medications that treat allergies such as Zyrtec or Allegra. Most people don’t realize that most of the over the counter sleep aids also use antihistamines, such as Unisom, Zzzquil or Nyquil.
What is histamine? Histamine is an pro-inflammatory compound released by white blood cells called mast cells as a response to injury and infection (especially as a response to allergens). The presence of histamine in your sinus and nasal pathways, for example, is why your sinuses get congested and your nose starts to run when you have allergies. They play an important role in regulating immunity and inflammation. Unfortunately, some individuals have a genetic mutation of the enzymes that degrade histamine in the body, leading to a chronic buildup of excess histamine in the body and the condition known as “histamine intolerance”. (There is also a more serious autoimmune condition called mast cell activation disorder.)
Mast cells are found in almost all tissues of the body, with high concentrations in the skin, gut lining, lung and heart, blood vessels, and a very high concentration in the brain and central nervous system. Symptoms of histamine intolerance include skin flushing, hives, headaches and migraines, digestive symptoms like diarrhea, eczema, anxiety, and allergic rhinitis. Histamine intolerance can also cause more serious symptoms like asthma attacks, anaphylactic shock, heart irregularities, and Crohn’s disease.
Within the brain, histamine actually plays a large role in regulating the cycle of sleeping and waking, and has an impact on our circadian rhythms or “biological clock”. Insufficient histamine can lead to excessive somnolence or sleeping, and an excess amount can lead to insomnia--common in individuals who suffer from histamine intolerance.
Solutions: If you suffer from insomnia and you are also someone with frequent allergies, or if you frequently suffer from some or many of the symptoms listed above, it would be advisable to look into the possibility that you are histamine intolerant. While taking over the counter antihistamines might seem like a simple solution (and indeed may provide relief), a number of clinical studies have found that long-term use of antihistamines predispose individuals to dementia or Alzheimer’s.
The best treatment for an excess of histamine is actually through regulating your diet. Many foods contain high levels of histamine, including avocados, fermented foods like kombucha and sauerkraut, aged cheeses, bone broth, tomatoes, and alcohol. Reducing or eliminating some or the majority of these foods can make a significant difference in someone with histamine intolerance. (You can think of it as filling up a bucket with histamine. When you overflow the bucket is when the symptoms emerge. So you need to keep your dietary intake to a place where the symptoms remain under control. This can take a certain amount of self-experimentation.)
Unfortunately, there is a lot of misleading and conflicting information on the internet as to which foods to avoid. I highly recommend starting with The Beginner’s Guide to Histamine Intolerance by Dr Janice Joneha, who spent a number of decades researching and treating this condition. Reducing your overall histamine intake and especially avoiding those foods close to bedtime should help to improve sleep length and quality.
Finally, there are also some natural antihistamine supplements you can explore, such as quercetin, or D-Hist (available through our DCA apothecary).
7) Electromagnetic radiation. Last but certainly not least, I think we all underestimate the effect that electromagnetic pollution is having on our environment, and also on our sleep. Electromagnetic radiation is the kind of radiation that emanates from visible light, but also radio waves, gamma waves, and X-rays. It emanates from all your electrical, computer and cell phone devices, from power lines and wifi. Especially if you live in a city, but even if you are close to a cell phone tower, you are being continually barraged these days with electromagnetic radiation.
This actually ties in very closely with the first cause I listed here--stress. Electromagnetic radiation today is causing a great deal of continual physiological stress on cellular level that I believe is causing a great deal of physical harm and damage. There have been a number of studies linking childhood leukemia to living near high voltage power lines. Other studies have shown direct continual oxidative damage (free radical damage) to human tissues during prolonged exposure. The more I look into and research this--the more concerned I become. Indeed, the United States has really lagged behind in this critical research. Schools worldwide, initially led by France, have starting banning wi-fi in kindergarten, and reducing wifi within schools in general. The “birth” of 5G has increased this risk exponentially.
Solutions: If you want to look more deeply into ways to reduce your home and office electromagnetic exposure, there are luckily many good resources out there, such as this one on Amazon. Obviously, keeping all cell phones away from your bedroom, and turning off your home wifi system every night is at least a start. I took a risk and bought a device from Germany called G Waveguard, and immediately started sleeping much better after I installed it. This is unfortunately uncharted territory, but I believe the more you seek to find solutions, the better for yourselves, your family, and your pets.
It should go without saying that regular acupuncture is also a wonderful support for sleep! When people are coming in for insomnia, I usually recommend a series of at least weekly acupuncture for 2-3 months, tapering to biweekly then monthly once good improvement is made. Acupuncture reduces stress and inflammation, balances hormones, promotes improved central nervous system function, and balances the body electromagnetically.