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Chapter on Sleep, “Peace and Purpose”

Histamine     

Histamine controls many body functions and is a key part of your body’s response to inflammation. Which histamine receptors histamine binds to determines what effect it has. Scientists have found four different kinds of histamine receptors. Excess histamine can cause anxiety as well as insomnia.  

H1 receptors

You have H1 receptors all over your body, including in neurons (brain cells), smooth muscle cells in your airways, and blood vessels. When the H1 receptors are turned on, allergy and anaphylaxis symptoms show up. It can lead to:

• Itchy skin (pruritus)
• Anxiety
• Expanding of blood vessels (vasodilation)
• Hypotension (low blood pressure)
• Increased heart rate (tachycardia)
• Flushing
• Narrowing of your airway (bronchoconstriction)
• Pain
• Movement of fluids through blood vessel walls (vascular permeability)

 Some of these changes in the body cause sneezing, stuffy nose, and a runny nose (rhinorrhea). H1 receptors do more than just control allergic reactions. They also help:

• Sleep-wake cycles
• Food intake
• Body temperature
• Emotions
• Memory
• Learning

Of course, its effect on Sleep-wake cycles is our current concern. It’s like our balance from within. Our sleep-wake cycle is essential when it comes to finding peace and purpose in life.           

Histamine is considered wake-promoting because drowsiness is a common side effect of certain anti-allergy medications that block histamine signaling. Also, histamine neurons are generally active in wake states and inactive during sleep. Histamine neurons promote wakefulness by activating neurons in the cortex that cause arousal and by inhibiting neurons that promote sleep. So, basically, histamine keeps you awake.  

Balance From Within: How to Reduce Histamine Naturally           

Foods that reduce histamine:

• Apples
• Onions
• Pineapple
• Parsley
• Blueberries
• Olive oil

Vitamin C reduces histamines, as well, so any foods containing vitamin C may reduce histamine. Foods to avoid if you trying to reduce histamine:

• Kombucha
• Sauerkraut
• Wine or beer
• Aged meats or cheese
• Olives
• Vinegar
• Canned meats/fish
• Tomatoes
• Ketchup
• Avocados
• Spinach

Supplements that may help reduce histamine:

• Forskolin
• Quercetin
• Astragalus
• Vitamin C
• B. longum (probiotic strain)
• B. infantis (probiotic strain)
• Erythropoietin
• Pancreatic enzymes (ask a doctor before use)
• Methylxanthines (Dietary sources of methylxanthines include coffee, tea, chocolate, maté, and guarana. You can drink coffee, eat chocolate, or supplement with theobromine, but attempting to supplement with theophylline is not recommended, as adverse cardiac effects are possible. However, chocolate also contains some histamine, and researchers suspect that it may encourage histamine release. The net effect of cocoa is unknown; it’s recommended that you test your own individual response and see what it does for you.)
• Fisetin
• Luteolin (found in celery, parsley, and broccoli)
• Apigenin (found in parsley, grapes, and apples)
• EGCG (found in green tea)
• Kaempferol (found in cruciferous vegetables, delphinium plants, witch hazel, and grapefruit)
• Myricetin (found in berries, teas, wines, and many vegetables)
• Rutin (found in buckwheat, apples, and passionflower)
• Theanine (found in green and black tea)
• Naringenin (found in grapefruit)
• Curcumin (found in turmeric)
• Reishi mushroom
• Chinese Skullcap
• Eleuthero (also known as Siberian ginseng)
• Tulsi (also known as holy basil)
• Mucuna pruriens (also known as velvet bean)
• Vitamin B6
• L. plantarum (a probiotic)
• Palmitoylethanolamide (PEA)
• SAM-e (S-adenosyl-L-methionine)
• Carnosine (made from the amino acids beta-alanine and histidine and found in high-quality meat)
• NAC (N-acetyl cysteine)
• Valine (found in meat, grains, vegetables, and milk and other dairy products)

Drugs that reduce histamine:

• alimemazine (trimeprazine)
• brompheniramine
• chlorphenamine
• dexchlorpheniramine
• diphenhydramine (Benadryl)
• doxylamine (often sold under the brand name “Unisom,” though Unisom sometimes contains diphenhydramine instead)
• pheniramine
• promethazine
• triprolidine
• hydroxyzine

These should be reserved for occasional, short-term use only. You can quickly develop tolerance to them, and side-effects may occur with prolonged use.  

Cortisol

Cortisol is a steroid hormone that is made and released by your adrenal glands and is also important in our pursuit of peace and purpose. These glands are endocrine glands that sit on top of your kidneys. Cortisol affects many parts of your body, but its main job is to control how your body reacts to stress. Cortisol is a hormone called a glucocorticoid that is made and released by your adrenal glands. Glucocorticoids are a kind of hormone called a steroid. They stop inflammation in your body’s tissues and keep your muscles, fat, liver, and bones from breaking down too quickly.

Glucocorticoids also change the way people sleep and wake up. Your body checks your cortisol levels all the time to keep them steady (this is called homeostasis). Cortisol levels that are either too high or too low can be bad for your health. People often call cortisol the “stress hormone.”

But it does a lot more than just control your body’s stress response. It has many important effects and functions all over your body. Also, it’s important to keep in mind that, from a biological point of view, there are many kinds of stress, such as:

• Acute stress: This kind of stress happens when you are suddenly and for a short time in danger. Acute stress can be caused by things like barely avoiding a car accident or being chased by an animal.
• Chronic stress: This is long-term stress that happens when you must deal with things that make you angry or worried over and over again. Chronic stress can be caused by things like having a job that is hard or frustrating or being sick all the time.
• Traumatic stress: This happens when you go through something that puts your life in danger and makes you feel scared and helpless. Traumatic stress can be caused by things like being in a war or being sexually assaulted or going through a tornado. Post-traumatic stress disorder (PTSD) can sometimes be caused by these things.

When any of these things stress you out, your body makes cortisol.

How does my body react to cortisol?

When you’re stressed, your body can release cortisol after releasing “fight or flight” hormones like adrenaline. This keeps you on high alert. In times of stress, cortisol also makes your liver release glucose (sugar) so that you can get energy quickly. Cortisol helps control how your body uses fats, proteins, and carbs for energy by regulating your metabolism. Normally, your cortisol levels are lowest in the evening when you go to sleep and highest in the morning before you wake up. This suggests that cortisol is a key part of waking up and is involved in the circadian rhythm of your body. Cortisol levels need to be just right for people to live and for their bodies to work properly. If your cortisol levels are consistently high or low, it can be bad for your health. High cortisol levels can cause anxiety.  

How does my body keep the level of cortisol in check?

Your body has a complicated system to control how much cortisol you have in your body. Your hypothalamus, which is a small part of your brain that controls hormones, and your pituitary gland, which is a small gland below your brain, controls how much cortisol your adrenal glands make. When the amount of cortisol in your blood drops, your hypothalamus releases corticotropin-releasing hormone (CRH), which tells your pituitary gland to make adrenocorticotropic hormone (ACTH). Then, ACTH tells your adrenal glands to make cortisol and let it out. Your hypothalamus, pituitary gland, and adrenal glands must all be working well for you to have the right amount of cortisol in your body.

How can I find out how much cortisol I have?

Your doctor can test your blood, urine, or saliva to see how much cortisol is in your body. Based on your symptoms, they will decide which test is best.  

How much cortisol is normal?

Cortisol is a hormone that is found in your blood, urine, and saliva. Its level is highest in the morning and drops throughout the day, reaching its lowest point around midnight. If you work nights and sleep at different times, this pattern can change. The normal ranges for most tests that measure cortisol in your blood are:

• 10 to 20 micrograms per deciliter (mcg/dL) from 6 to 8 a.m.
• 3 to 10 mcg/dL around 4 p.m.

Normal ranges can be different from lab to lab, person to person, and over time. If you need a cortisol level test, your doctor or nurse will look at the results and tell you if you need more testing.

What makes cortisol levels so high?

Hypercortisolism is the medical term for having abnormally high levels of cortisol for a long time. This is usually considered Cushing’s Syndrome, which is a rare condition. Causes of cortisol levels that are higher than normal and Cushing’s Syndrome include:

• Taking a lot of corticosteroid drugs like prednisone, prednisolone, or dexamethasone to treat other health problems.
• Tumors that produce adrenocorticotropic hormone (ACTH). These are usually found in your pituitary gland. More rarely, neuroendocrine tumors in other parts of your body such as your lungs can cause high cortisol levels.
• Adrenal gland tumors or excessive growth of adrenal tissue (hyperplasia), which cause excess production of cortisol.

What are the signs that your cortisol levels are too high?

Depending on how high your cortisol levels are, your symptoms of Cushing’s Syndrome will be different. Common signs and symptoms of cortisol levels that are higher than normal are:

• Weight gain, especially in your face and abdomen.
• Anxiety
• Fatty deposits between your shoulder blades.
• Wide, purple stretch marks on your abdomen (belly).
• Muscle weakness in your upper arms and thighs.
• High blood sugar, which often turns into Type 2 diabetes.
• High blood pressure (hypertension).
• Excessive hair growth (hirsutism) in women.
• Weak bones (osteoporosis) and fractures.

What causes cortisol to be low?

When cortisol levels are lower than normal, this is called hypocortisolism. This is a sign of adrenal insufficiency. There are two kinds of adrenal insufficiency: primary and secondary. Some things that can cause adrenal insufficiency are:

• Primary adrenal insufficiency: Most of the time, your immune system attacks healthy cells in your adrenal glands for no known reason, which can cause primary adrenal insufficiency. The name for this is Addison’s disease. Your adrenal glands can also be hurt by an infection or bleeding in the tissues (called an adrenal hemorrhage). All these things stop cortisol from being made.
• Secondary adrenal insufficiency: If you have hypopituitarism or a tumor on your pituitary gland, it can stop your body from making enough ACTH. ACTH tells your adrenal glands to make cortisol, so when there isn’t enough ACTH, there isn’t enough cortisol made.

Corticosteroid medications can also cause cortisol levels to be lower than normal, especially if you stop taking them quickly after using them for a long time.  

What are the signs that your cortisol levels are too low?

If your cortisol levels are lower than normal, this is called adrenal insufficiency.

• Fatigue
• Anxiety
• Unintentional weight loss
• Poor appetite
• Hypotension (low blood pressure)

How can I lower my level of cortisol?

If you have Cushing’s syndrome, which is when your cortisol levels are very high, you will need medical treatment to bring them down. Most treatments involve either medicine or surgery. If your cortisol levels are lower than normal, you’ll also need medical help. In general, though, there are a few simple things you can do every day to try to lower your cortisol levels and keep them where they should be.

• Get good sleep: Sleep problems like obstructive sleep apnea, insomnia, or working the night shift can cause cortisol levels to rise.
• Regular exercise: Several studies have shown that regular exercise can help you sleep better and feel less stressed, which can lower your cortisol levels over time.
• Learn to control stress and stressful ways of thinking: Knowing how you think, how you breathe, how fast your heart beats, and other signs of stress can help you catch it early and stop it from getting worse.
• Do exercises that help you take deep breaths: Your parasympathetic nervous system, or “rest and digest” system, is activated when you breathe in a controlled way. This helps lower cortisol levels.
• Have fun and laugh: Laughing makes endorphins come out and stops cortisol from coming out. Having hobbies and doing fun things can also make you feel better, which may make your cortisol levels go down.
• Keep your relationships in good shape: Relationships are an important part of our life. Having tense, unhealthy relationships with people you care about or work with can cause you to feel stressed out often and raise your cortisol levels.

 When should I talk to my doctor about my cortisol levels?

If you have signs of Cushing’s syndrome or adrenal insufficiency, you should see a doctor. If you are worried about how stressed you are every day, talk to your doctor or nurse about what you can do to reduce your stress and stay healthy. Cortisol is a very important hormone that affects a lot of different parts of your body. There are a few things you can do to try to reduce your stress and, by extension, your cortisol levels. However, sometimes you can’t help whether your cortisol levels are too high or too low. If you gain or lose weight, or if your blood pressure goes up or down, these are signs that your cortisol levels are too high or too low. You should talk to your doctor about this. They can do some simple tests to find out if your symptoms are caused by your adrenal glands or your pituitary gland.

Balance From Within – Foods that lower cortisol:

• Avocados
• Bananas
• Broccoli
• Dark Chocolate
• Seeds
• Spinach
• Nutritional yeast
• Probiotics
• Olive Oil
• Nuts
• Adaptogens such as mushrooms, moringa and ashwagandha
• Cinnamon

Supplements that lower cortisol:

• Ashwagandha
• Omega-3s
• Prebiotics
• Probiotics
• Rhodiola Rosea
• Bacopa Monnieri
• Ginkgo Biloba
• Cordyceps
• Phosphatidylserine
• L-theanine

Norepinephrine Norepinephrine is a neurotransmitter and a hormone. It is also called noradrenaline. It is a key part of the “fight-or-flight” response in your body. Norepinephrine is also a drug that is used to raise and keep blood pressure high in short-term, serious health situations. As a neurotransmitter, norepinephrine is made from dopamine. Norepinephrine is made by nerve cells in your brainstem and in an area close to your spinal cord. Norepinephrine is a part of your body’s sympathetic nervous system, which is part of your “fight-or-flight” response to danger. The “fight or flight” response is called the “acute stress response” in medicine. If you have too much norepinephrine, you may feel anxious or on edge.  
 How does the body use norepinephrine?

• It makes you more awake, alert, and focused.
• Blood vessels get smaller, which helps keep blood pressure steady when you’re stressed.
• Changes the way you sleep, how you feel, and what you remember.

What sets off the release of norepinephrine?

Norepinephrine is a hormone that comes out of your adrenal glands when you’re stressed, when your tranquil waters are disturbed. The fight-or-flight response is the name for the changes in your body that happen because of this response.  

What does “fight or flight” mean?

The fight-or-flight response is how your body reacts to stressful situations, like when you need to get away from a dangerous situation (like a dog that is growling) or when you have to face a fear (like giving a speech for school or work). It’s the opposite of tranquil waters. During the fight-or-flight response, your brain tells you that something bad is happening. Then, nerves in a part of your brain called the hypothalamus send a message down your spinal cord and out to the rest of your body. Norepinephrine is the neurotransmitter that tells your nervous system what to do when your brain tells it what to do. The neurotransmitter noradrenaline goes to these organs and tissues and causes these quick reactions in the body:

• Eyes: The pupils get bigger to let in more light so you can see more of what’s around you.
• Skin: Your skin goes pale when your blood vessels get a message to send blood to places that need it more, like your muscles, so you can fight or run away.
• Heart: The heart beats harder and faster to get more oxygenated blood to places like your muscles that need it most. Also, blood pressure goes up.
• Muscles: When muscles get more blood flow and oxygen, they can move and work faster and with more strength.
• Liver: Your liver turns the glycogen you have stored into glucose, which gives you more energy.
• Airways: People breathe faster and deeper. Your airways widen, which lets more oxygen into your blood, which then goes to your muscles.

Your adrenal gland releases the hormones adrenaline (epinephrine) and noradrenaline (norepinephrine) when the neurotransmitter noradrenaline gets to it. These hormones get to every part of your body through your blood. They go back to your eyes, heart, lungs, skin, blood vessels, and adrenal gland. The “message” to these organs and tissues is to keep reacting until the danger is gone. Norepinephrine is used as a medicine to raise and keep blood pressure up in situations where low blood pressure is a problem, but only for a short time. Some of these conditions could be:

• Cardiac arrest
• Spinal anesthesia
• Septicemia
• Blood transfusions
• Drug reactions

  Low levels of norepinephrine can cause the following health problems:

• Anxiety
• Depression
• ADHD
• Headache
• Memory problems
• Sleeping problems
• Hypotension (low blood pressure)
• Low blood sugar (hypoglycemia)
• Blood pressure and heart rate changes
• Dopamine beta-hydroxylase deficiency. Your body can’t turn dopamine into norepinephrine if you have this rare genetic disease

High levels of epinephrine can cause the following health problems:

• High blood pressure
• Rapid or irregular heartbeat
• Excessive sweating
• Pale or cold skin
• Frequent headaches
• Nervous feeling, jitters
• Pheochromocytoma, which is a growth on the adrenal glands

  People with high levels of norepinephrine are more likely to hurt their heart, blood vessels, or kidneys. To lower norepinephrine, it’s important to find ways to put your body into parasympathetic response mode, so anything in nature that can help you relax will do. Norepinephrine levels can be kept in check by eating a well-balanced diet, reducing emotional and physical stress, getting enough sleep, and exercising regularly.  

• Nutrition

A well-balanced diet has been shown to help keep your immune system healthy and give you the extra energy you need to deal with stress. Early research suggests that omega-3 fatty acids and vegetables may help control cortisol levels. Mindful eating reduces stress by encouraging people to take deep breaths, choose their food carefully, pay attention to the meal, and chew their food slowly and thoroughly. This can also help your body digest better.

• Herbs and Supplements

Calming amino acids like a theanine supplement can help support norepinephrine levels, and nervine botanicals like lemon balm, kava, and chamomile, which work on the nervous system, can help naturally lower norepinephrine levels. There has been a lot of research on how adaptogenic herbs like ashwagandha can help the nervous system adapt to stressors, which can reduce stress and anxiety in people who use them regularly. Melatonin has been shown to lower the amount of norepinephrine in the body because it helps the sympathetic tone.

• Lifestyle

Physical activity can help lower stress hormones and blood pressure. Aerobic exercise raises your heart rate and breathing rate, which lets more oxygen flow through your body. Meditation, yoga, and tai chi all focus on deep breathing, which can help the parasympathetic nervous system help fight stress. Some research shows that using cognitive behavioral therapy (CBT) can help lower norepinephrine levels, which are often high in people who are anxious or angry.  

Supplements

Many supplements are known to assist sleep and help you return to tranquil waters. Here are some of the better known and more widely used and studied ones available.

• Lavender

Lavender oil seems to have a soothing effect and reduces anxiety and restlessness. Most studies on lavender’s efficacy as a sleep aid have focused on lavender essential oil, though some people also use the dried herb as a tea or in their pillow. Essential oils should not be ingested except under a doctor’s supervision, as even lavender oil contains poisonous compounds. Instead, the oil should be diffused into the air or diluted in a neutral cream or oil for use on the skin. Lavender may be most appealing for people who struggle to sleep due to anxiety or racing thoughts. It is also popular among people who want an external sleep aid rather than something they consume. Short-term use of dried lavender or use of lavender essential oil is thought to be safe, though potential side effects for the external use of lavender oil include skin irritation and allergic reaction. Lavendar is also available as a clinically-studied supplement called Lavela WS 1265.

• Valerian

Valerian has been used for sleep problems since the 2nd century and been known to help people fund extreme relief. Though further research needs to be done, valerian appears to help people fall asleep faster, sleep better, and wake up less often. In some studies, patients taking valerian were 80% more likely to report sleep improvements than those taking a placebo. Because experts have not located a single active compound, they speculate that valerian’s effect may be due to several compounds working together, or the amino acids GABA or glycine. The roots and stems of the valerian plant are made into teas, tinctures, capsules, extracts, and tablets. While each type of preparation has its fans, the tea can have an unpleasant odor, and researchers generally use liquid extracts or capsules in their research. Valerian is usually recommended for people with insomnia or general problems with sleep quality. Most people report that it is more effective once they have been taking it for several weeks. However, further research is needed to determine how effective valerian is in treating insomnia. Valerian is generally considered safe for adults. Side effects are rare and tend to be mild but may include headache, dizziness, itching, and upset stomach.

• German Chamomile

German chamomile has been used to treat sleep problems since ancient Egypt. Despite this long history, there has been little research into its benefits. What we do know from smaller studies and meta-analysis is that German chamomile may soothe anxiety and improve sleep quality, although researchers are not clear on why it might have these effects.

On the other hand, it does not appear to benefit people with insomnia. The most common preparations of German chamomile are capsules, tincture, and tea. Although there is another variety called Roman chamomile, most research has focused on the German type. Chamomile is generally regarded as safe when used as a tea or taken orally. It does have potential interactions with some drugs, including blood thinners, and there is little information on its safety for those who are pregnant or breastfeeding. Side effects are usually limited to mild nausea or dizziness, but allergic reactions are possible, particularly for people with allergies to related plants like ragweed and daisies.

• Passionflower

The passionflower vine is native to the Americas and has historically been used as a sedative by multiple indigenous cultures. There has been very little research into its benefits, though the existing research is encouraging, if limited. In one study focused on generalized anxiety disorder, passionflower’s calming effects were comparable to a commonly prescribed sedative. Passionflower may also improve sleep quality and make it easier to fall and stay asleep. Extracts and tea are both common forms of passionflower people use. Both have been used in research settings, so choosing between them is a matter of preference.

While research into this supplement shows potential benefits for anxiety and insomnia, there is no conclusive proof of its efficacy. There is little research into its safety. However, daily doses of up to 800 milligrams have been used safely in studies lasting as long as two months. Side effects are usually mild and may include drowsiness, confusion, and uncoordinated movements. Pregnant women should not use passionflower, as it can induce uterine contractions. There is limited research into its safety while breastfeeding.

• Hops

In addition to being the main flavoring in beer, the flowers of the hops plant are used by some people as a natural sleep aid. Like most natural supplements, the benefits of hops have not been researched enough to definitively state whether it might help people sleep better. However, there is preliminary evidence that hops supplements can help stabilize circadian rhythms and lessen the symptoms of shift work disorder.

Dried hops flowers contain the acids humulone and lupulone, and their relationship with the body’s GABA receptors may be part of the reason for hops’ effects. Hops is often combined with other Natural Sleep Aids such as valerian. It can be taken as non-alcoholic beer or in dried form as a tea or dry extract. Different studies have used all three methods, and there is no evidence in favor of one form over another. It is likely safe to consume hops in the form of non-alcoholic beer or tea, though supplemental use is only considered possibly safe due to the lack of research. Hops also has more potential side effects than some other natural sleep aids.

Because it has weak effects similar to estrogen, hops can cause changes to the menstrual cycle and is not recommended for people who are pregnant or breastfeeding, or who have hormone-sensitive cancers or other conditions. Hops can also worsen depression. However, for most people, side effects are mild and may include dizziness or sleepiness.  

• Cannabidiol (CBD)

CBD is a chemical known as a cannabinoid that is present in the cannabis plant. Cannabis has over 100 cannabinoids, and CBD is much different than the psychoactive delta-9-tetrahydrocannabinol (THC) cannabinoid. Most CBD is derived from hemp, which does not contain enough THC to be psychoactive. Research into CBD has previously been limited due to cannabis regulations, but there are indications that it might help some people sleep better. To begin with, it appears to reduce the anxious symptoms of a broad spectrum of mental health conditions. It also seems that the body’s own cannabinoid system affects how we sleep, making CBD more likely to have benefits.

There has been some evidence that CBD can aid some sleep disorders and reduce excessive daytime sleepiness, but research is currently inconclusive. Although CBD has been legal federally since 2018, it is not supposed to be sold as a dietary supplement. It is, however, widely available in forms such as tinctures, gummies, and oils. Because of this lack of regulatory oversight, one study found that 26% of CBD products had less CBD than they claimed, while 43% had much more. CBD appears to be largely safe with minor side effects such as tiredness, diarrhea, and changes to weight or appetite. However, its safety is unknown for people who are pregnant or breastfeeding CBD may interact with medications and adversely impact certain health conditions.

• Tart Cherry Juice

Juice from the tart cherry, also known as the sour cherry, appears to raise melatonin levels and increase the availability of tryptophan, an amino acid that may play a role in helping people fall asleep. These are promising findings, and tart cherry juice may improve sleep quality and make it easier to fall asleep. However, some studies indicate that the effect on insomnia is not as strong as established treatments like cognitive-behavioral therapy. Studies on the health benefits of tart cherries have had participants consume the equivalent of up to 270 cherries a day, but there is no specific research into their safety. The juice, which can be very sour, is usually diluted in a small amount of water before drinking.

• Magnesium

Magnesium is a mineral naturally present in food and often added to processed foods. It is used throughout the body and is present in bones, soft tissue, and blood. Older adults are more at risk for magnesium deficiency, and one of the mineral’s many roles is sleep regulation. Some research suggests that supplemental magnesium may help reduce insomnia in older adults, either when used alone or with melatonin and zinc. It may also reduce excessive daytime sleepiness in adults.

Since high levels of magnesium are available in foods like pumpkin seeds, it is easy to supplement by eating more magnesium-rich foods. Magnesium supplements are also available in pills and tablets, including multivitamins. Magnesium aspartate, magnesium citrate, magnesium lactate, and magnesium chloride are the easiest for the body to absorb. While magnesium is usually safe at ordinary dietary levels since the kidneys filter it out, high dosages can cause side effects like diarrhea, nausea, and abdominal cramping.

Magnesium also interacts with some medication and other supplements, and very large dosages can lead to significant heart abnormalities including low blood pressure or hypotension, irregular heartbeat, and cardiac arrest.

• GABA

Gamma-aminobutyric acid (GABA) is an amino acid and neurotransmitter that plays a vital role in regulating nervous system activity and can possibly provide extreme relief. In addition to being made by the body and present in food like tea and tomatoes, GABA is available in supplement form. While it was previously believed that GABA taken orally could not pass the blood-brain barrier and was therefore not useful to the body, there is now some evidence to the contrary Small trials of supplemental GABA have shown that it can reduce stress and may help people fall asleep more easily.

It is not currently known whether GABA’s effects on sleep might be due to stress reduction or another mechanism. GABA naturally occurs in the body and in food, but there is little research into whether it is safe to take as a supplement. However, most studies have shown no adverse reactions. GABA is available in pills and may be derived from natural or synthetic sources. Research is still ongoing as to whether synthetic GABA is as effective as GABA derived from a natural source.

• Glycine

Like GABA, glycine is an amino acid and neurotransmitter made by the body and available in some foods. Glycine appears to affect sleep and pass the blood-brain barrier. Studies show that glycine appears to improve sleep quality, potentially by lowering body temperature. Taking glycine before bed may also help reduce the negative effects of insufficient sleep, which may be due to improved sleep quality or another mechanism. Supplemental glycine is available in capsule or powder form, and there is limited knowledge about what form might be most beneficial. While glycine is part of our diet, its safety is unknown when taken in the quantities usually found in supplements.  

Are Natural Sleep Aids Safe?

Natural sleep aids are not universally safe or unsafe. Sold over the counter or online, natural sleep aids do not go through the same testing and review process as prescription medicines. In general, there is a lack of high-quality research about the effectiveness and safety of most natural sleep aids. As a result, many questions about natural sleep remedies remain unresolved. There are special considerations to keep in mind when evaluating the safety of natural sleep aids.

Adults

Many natural sleep remedies, when taken in the proper dosage by healthy adults, have few side effects. But this does not mean that all natural sleep aids are safe. As a precaution, adults should talk with their doctor or pharmacist before taking a natural sleep aid. Adults should also stop taking natural sleep aids if they notice any abnormal health changes or side effects.

Children

Some natural sleep aids may be safe for use in children, though sleep hygiene should be encouraged before sleep aids are considered. In many cases, there is insufficient research in children to confidently evaluate the safety or efficacy of natural sleep aids. For certain natural sleep aids, such as melatonin, short-term use is generally considered to be safe for most children, but there is limited data about long-term use. To make sure that any medication or sleep aid does not affect their child’s health and development, parents should take precautions when considering natural sleep aids for their children, including:

• Talking with their pediatrician first
• Ensuring that the dosage is meant for children and not adults
• Paying attention to the label and list of ingredients
• Looking for high-quality products that are tested by third parties to reduce the risk of tainted or mislabeled supplements

Pregnant or Breastfeeding

People who are pregnant or breastfeeding should use caution with natural sleep aids. Many ingredients have not gone through rigorous testing in people who are pregnant or breastfeeding, so little is known about potential effects on their child. Although some products may be safe, the best approach for those who are pregnant or breastfeeding is to consult with their doctor prior to taking natural sleep aids.

Should You Talk to a Doctor Before Taking a Natural Sleep Aid?

It is advisable to talk with a doctor before starting to use any natural sleep aid. Even though these products are available without a prescription, your doctor may be able to help in several ways:

• Reviewing your other medications and the potential for interactions between them and a natural sleep aid
• Addressing your health history and the likelihood of adverse reactions from natural sleep aids
• Understanding your sleeping problems and evaluating if they may be caused by an underlying sleep disorder that can be resolved with a more specific form of treatment
• Discussing the potential benefits and risks of specific types of natural sleep aids
• Offering suggestions about dosage or timing for taking natural sleep aids
• Providing guidance about how to know whether a natural sleep aid is working or causing side-effects

Cognitive Behavioral Therapy for Insomnia (CBT-I)            

Cognitive behavioral therapy for insomnia (CBT-I or CBTI) is a short, structured, and evidence-based way to deal with the frustrating symptoms of insomnia and a proven way to find extreme relief. 

How it Works

CBT-I tries to figure out how the way we think, what we do, and how we sleep are all linked. During treatment, a trained CBT-I provider helps figure out what thoughts, feelings, and actions are causing the insomnia symptoms. Thoughts and feelings about sleep are looked at and tested to see if they are true. Behaviors are also looked at to see if they help people get to sleep. Then, a provider will clear up or reframe any misunderstandings or problems in a way that makes it easier to sleep. Most treatments take between 6 and 8 sessions. The length can vary depending on what a person needs. When given by a primary care doctor, treatment can be as short as two visits.         

People often call CBT-I a “multicomponent treatment” because it uses more than one method. Sessions can have educational, cognitive, and behavioral parts. Cognitive interventions include “cognitive restructuring,” which tries to change wrong or harmful ideas about sleep. Behavior changes can include relaxation training, controlling stimuli, and limiting sleep. All these help people relax and get into good sleep habits. At the heart of CBT-I is giving information about how thoughts, feelings, behaviors, and sleep are connected. The order and flow of each part can change based on how the provider works and what each person needs. Here are some CBT-I techniques that are often used:  

Cognitive Restructuring

People with insomnia may have wrong or dysfunctional thoughts about sleep, which can make them do things that make it harder to sleep. This reinforces the wrong or dysfunctional thoughts. For example, having trouble sleeping before can make it hard to fall asleep again. This worry might make you stay in bed for too long to try to sleep. Both stress and spending too much time in bed can make it harder to fall asleep and stay asleep. This can turn into a frustrating nightly pattern that can be hard to break.

Cognitive restructuring starts to break this cycle by identifying, challenging, and changing the thoughts and beliefs that lead to insomnia. During treatment, common thoughts and beliefs that may be addressed include anxiety about past episodes of insomnia, having unrealistic expectations about sleep time and quality, and worrying about being tired during the day or other effects of not getting enough sleep. With the help of a trained provider who can help evaluate them more objectively, inaccurate thoughts can be found, challenged, and changed. Homework is often given so that students can practice these skills when they are not in class.  

Stimulus Control

People who can’t sleep start to dread going to bed because they associate it with being awake and frustrated. They may also think of their bedroom as a place where they do things that make it hard to sleep, like eat, watch TV, or use a cell phone or computer. Stimulus control tries to change how these things are linked. During treatment, the bed is only used for sleeping and making love. Clients are told to get out of bed if they can’t fall asleep or if they’ve been awake for more than 10 minutes. They should only go back to bed when they’re tired again. Clients are told to set their alarms for the same time every morning and not to nap during the day.  

Sleep Restriction and Compression

People with insomnia often lie awake in bed for too long. Sleep restriction limits how long a person can stay in bed so that they can get back on a regular sleep schedule. This technique is meant to make you want to sleep more and can temporarily make you feel more tired during the day. It is not recommended for people with health problems like bipolar disorder and seizures that can get worse when they don’t get enough sleep. Using a sleep diary, the first step in sleep restriction is to figure out how long a typical night of sleep is. The amount of time in bed is then changed by this amount plus 30 minutes.

For example, if a person wants to sleep 8 hours a night but only gets 5, they should change their bedtime so that they sleep for 5 hours and 30 minutes. Once a person spends most of their time in bed sleeping, they can start slowly extending the amount of time they spend there. Sleep compression is a slightly different method that is often used with older people because it is gentler. Instead of immediately cutting down the amount of time they spend in bed to the amount of sleep they get on an average night, the time they spend in bed is gradually cut down until it is close to the amount of time they spend sleeping.  

Relaxation Training

Relaxation techniques can help ease the stress and racing thoughts that come with lying awake in bed. These methods can boost the body’s natural ability to calm down. This is good for both the body and the mind. The best ways to relax are those that are easy to fit into a person’s daily life. Here are a few CBT-I techniques that are often used to help people relax: Breathing exercises: CBT-I can teach many different breathing exercises. Most of these exercises have you take slow, deep breaths. Research has shown that focused breathing can slow down your heart rate and breathing, as well as make you feel less anxious, angry, and sad.

Progressive Muscle Relaxation (PMR): PMR is a method in which different muscle groups are tense and then relaxed. These techniques can be used with guided imagery or breathing exercises. Autogenic training is a way to focus on different parts of the body and pay attention to certain feelings. A person can pay attention to feelings like weight, warmth, or relaxation. Biofeedback is a technique that uses technology to help keep track of things like brain waves, heart rate, breathing, and body temperature. People may be able to learn to have more control over these processes if they use the information that electronic devices give them. Guided or self-hypnosis can help people who have trouble sleeping by teaching them how to relax when given a verbal or non-verbal cue.

Meditation has many benefits, such as lowering stress and anxiety and making it easier to relax. Meditation can also be done through practices like yoga and tai chi that combine focused attention with movement.  

Psychoeducation

A core part of CBT-I is teaching clients how important good sleep hygiene is. Good sleep hygiene means doing more things that help you sleep and lessening or getting rid of things that make it hard to sleep. Some of the things that might be talked about are how diet, exercise, and the place you sleep affect your ability to fall asleep and stay asleep.  

Homework

CBT-I is a group process, and practicing the skills you learn in sessions is important. A common part of treatment is giving the patient homework. Between sessions, you might have to do things like keep a sleep diary, practice questioning automatic thoughts or beliefs when they come up and improve your sleep hygiene.  

Is CBT-I helpful?

When these techniques are used together as part of CBT-I with multiple components, between 70% and 80% of people with primary insomnia feel better. It takes less time to fall asleep, you sleep longer, and you wake up less often during sleep. Results tend to stay the same over time. For some people, CBT-I works better than medications. This treatment has also been shown to work for people who are more likely than others to have trouble sleeping, such as pregnant women.

CBT-I is thought to help with many kinds of insomnia. It may even help people with short-term insomnia. This means that CBT-I may be useful for treating insomnia symptoms even if they don’t meet the criteria for chronic insomnia. Even though this treatment for insomnia has been shown to be very effective, it doesn’t always work right away. It can take time to learn and use the skills that are taught in therapy.

Some methods, like controlling what you do before bed and getting less sleep, can help you change your sleep habits slowly. Some people find it helpful to keep track of their progress over time so they can see small improvements that can encourage them to keep going with treatment. If CBT-I alone doesn’t help with insomnia symptoms, the American College of Physicians suggests talking to a doctor about the risks and benefits of taking sleep medications along with CBT-I.  

Does CBT-I Have Risks?

For CBT-I to work, you need to be willing to face your negative thoughts and actions. Even though the risks of treatment are likely to be low, it may sometimes be painful. Talking about painful memories, thoughts, and feelings can be hard and may cause stress and discomfort in the short term. Working with a trained CBT-I professional can help reduce the risks of this treatment because they know how to give support and tools to deal with temporary problems or setbacks.  

Who Gives CBT-I?

CBT-I is usually given by a doctor, counselor, therapist, or psychiatrist who has been trained to do so. Professional groups like the Society of Behavioral Sleep Medicine and the American Board of Sleep Medicine can help you find CBT-I practitioners. There aren’t enough CBT-I professionals to meet the demand right now because so many people need this treatment. Researchers have come up with new ways to offer CBT-I, like digital, group, and self-help formats.  

Digital CBT-I

Several digital CBT-I (sometimes called dCBT-I or dCBT) apps have been made to keep up with this trend, lower the cost of treatment, and give more people access to the benefits of CBT-I. The Department of Veterans Affairs has its own app called CBT-I Coach. It can be used by both veterans and people who are not veterans. Different online resources and smartphone apps that offer dCBT-I have different purposes and require different amounts of help from the provider.

Some resources just help people while they work with a trained CBT-I provider in person, while others are fully automated and don’t need any help from a clinician. Other resources and apps are a mix of the two, letting people work through a pre-set program and have regular feedback sessions with a professional through e-mail or the phone. Digital CBT-I works well to treat insomnia in kids, teens, and adults.            

Even though only a few studies have directly compared dCBT-I and face-to-face approaches, it seems that both help people with insomnia feel better.  

Medication

In some cases, doctors will prescribe drugs for the treatment of insomnia. All insomnia medications should be taken shortly before bed. Do not attempt to drive or perform other activities that require concentration after taking an insomnia drug because it will make you sleepy and can increase your risk for accidents. Medications should be used in combination with good sleep practices. Here are some medications that can be used to treat insomnia:  

• Antidepressants

Some antidepressant drugs, such as trazodone (Desyrel), are very good at treating sleeplessness and anxiety.  

• Benzodiazepines

These older sleeping pills — emazepam (Restoril), triazolam (Halcion), and others — may be useful when you want an insomnia medication that stays in the system longer. For instance, they have been effectively used to treat sleep problems such as sleepwalking and night terrors. These medications have some serious downsides. They can cause addiction and dependence. Dependence means that you have physical withdrawal when you stop them. Also, there is a black box warning against their use with opioids, because both depress respiration and increase your risk of overdose.  

• Doxepine (Silenor)

This sleep drug is approved for use in people who have trouble staying asleep. Silenor may help with sleep maintenance by blocking histamine receptors. Do not take this drug unless you have time to get a full 7 or 8 hours of sleep.  

• Eszopiclone (Lunesta)

Lunesta also helps you fall asleep quickly, and studies show people sleep an average of 7 to 8 hours while on it. Don’t take Lunesta unless you are able to get a full night’s sleep as it could cause grogginess. Because of the risk of impairment the next day, the FDA recommends the starting dose of Lunesta be no more than 1 milligram.  

• Lemborexant (Dayvigo)

This drug is approved for people who have trouble falling asleep and staying asleep. It works by suppressing the part of the central nervous system that keeps you awake. It may cause you to feel sleepy the next day.  

• Ramelteon (Rozerem)

This sleep medication works differently than the others. It works by targeting the sleep-wake cycle, not by depressing the central nervous system. It is prescribed for people who have trouble falling asleep. Rozerem can be prescribed for long-term use, and the drug has shown no evidence of abuse or dependence.  

• Suvorexant (Belsomra)

It works by blocking a hormone that promotes wakefulness and causes insomnia. It is approved by the FDA to treat people that have insomnia due to an inability to fall asleep or to stay asleep. The drug may cause you to feel sleepy the following day.  

• Zaleplon (Sonata)

Of all the newer sleeping pills, Sonata stays active in the body for the shortest amount of time. That means you can try to fall asleep on your own, then, if you’re still staring at the clock at 2 a.m., you can take it without feeling drowsy in the morning. But if you tend to wake during the night, this might not be the best choice for you.  

• Zolpidem (Ambien, Edluar, Intermezzo)

These medicines work well at helping you get to sleep, but some people tend to wake up in the middle of the night. Zolpidem is now available in an extended-release version, Ambien CR. This may help you go to sleep and stay asleep longer. The FDA warns that you should not drive or do anything that requires you to be alert the day after taking Ambien CR because it stays in the body a long time. You should not take zolpidem unless you are able to get a full night’s sleep — at least 7 to 8 hours.

In rare instances, these medications have been known to cause injuries because of behaviors while asleep or partially asleep such as sleep walking and sleep driving, among others. The FDA has approved a prescription oral spray called Zolpimist, which contains zolpidem, for the short-term treatment of insomnia brought on by trouble falling asleep. If these medications don’t work for you, your doctor may suggest something off-label. These are medications used to treat conditions they weren’t originally made for.

Older antidepressants are sometimes prescribed to treat insomnia because they change brain chemicals, which can help regulate sleep. These older medications also tend to have a sedative effect or make you sleepy. They include:

• Amitriptyline (Elavil)
• Mirtazapine (Remeron SolTab, Remeron)
• Nortriptyline (Aventyl, Pamelor)
• Trazodone
• Gabapentin
• Tiagabine

 The FDA issued warnings for prescription sleep drugs, alerting patients that they can cause rare allergic reactions and complex sleep-related behaviors, including “sleep driving.” They also warned people that taking sleeping medication at night can impair their ability to drive or be fully alert — even the next day. Keep in mind that sleep drugs are not for long-term use.

Talk to your doctor if you’re still having trouble sleeping after 2 weeks. For a short time, a sleeping pill can help you sleep better. But it’s important to know everything about sleeping pills that you need to know. That means knowing about the side effects of sleeping pills. If you do, you can avoid using these sleep aids in the wrong way.  

What are sleeping pills?

The name for most sleeping pills is “sedative hypnotics.” That’s a group of drugs that help people fall asleep or stay asleep. Benzodiazepines, barbiturates, and other hypnotics are examples of sedative hypnotics. Anti-anxiety drugs like Ativan, Librium, Valium, and Xanax are called benzodiazepines. They also make people feel sleepy and help them fall asleep. Halcion is an older sedative-hypnotic benzodiazepine drug that has been mostly replaced by newer drugs. Even though these drugs may help in the short term, all benzodiazepines have the potential to become addicting and can make it hard to remember things and pay attention.

Most of the time, they are not recommended as a long-term solution for trouble sleeping. Barbiturates are another type of sedative-hypnotic drug. They slow down the central nervous system and can make you sleepy. As sedatives or sleeping pills, barbiturates can have a short or long effect.

Most of the time, though, these drugs are only used as anesthesia. If you take too much, they can kill you. Newer drugs help you fall asleep more quickly. Ambien, Lunesta, and Sonata are all sleep-inducing drugs that bind to the same brain receptors as benzodiazepines. They are less likely to cause physical dependence than benzodiazepines, but they can still sometimes do so over time. They can work quickly to make you feel sleepy and help you fall asleep.

Rozerem is a different kind of sleep aid from the ones we’ve already talked about. It changes melatonin, a hormone in the brain, and it’s not addictive. Belsomra is a unique sleep aid that works on a chemical in the brain called orexin. It is not addictive. Silenor, a low-dose version of the tricyclic antidepressant doxepin, is another non-addictive sleep aid.  

What do sleeping pills do to your body?

Like most medicines, sleeping pills can make you feel bad in other ways. But you won’t know if a certain sleeping pill will cause side effects until you try it. If you have asthma or other health problems, your doctor may be able to tell you about some side effects. Sleeping pills can make it hard to breathe normally and can be dangerous for people with asthma, emphysema, or some types of chronic obstructive pulmonary disease (COPD), which is a lung disease that makes it hard to breathe. Sleeping pills like Ambien, Halcion, Lunesta, Rozerem, and Sonata often have the following side effects:

• Hands, arms, feet, or legs that burn or tingle
• Changes in appetite
• Constipation
• Diarrhea
• Balance problems
• Dizziness
• Day-time drowsiness
• Dry throat or mouth
• Gas
• Headache
• Heartburn
• Impairment the following day
• Slowing of the mind or trouble paying attention or remembering
• Pain or tenderness in the stomach
• Shaking of a body part that can’t be stopped
• Unusual dreams
• Weakness

It’s important to know about the possible side effects of sleeping pills so you can stop taking them and cal