In this comprehensive article on insomnia, I describe the most common treatments for sleeplessness. I begin with Western Medicine’s pharmacologic treatment, which is very efficient but its effects are not lasting. Then, I take a look at various cognitive, spiritual and behavioral treatments, which have a curative value, but are not always effective. I go over some herbal remedies which have been put to the test for treatment of insomnia before I introduce my own approach which I refer to as Paleolithic Sleep. I believe that compared to how we existed for the most part of our existence as a species, in our modern life we are making lifestyle choices that in some predisposed individuals become insomnia. Once you get used to living on a healthy schedule as well as adopt a balanced diet and a relaxed state of mind, insomnia goes away.
By the time you finish reading this article, you will know exactly what you need to do and change in your life in order to attain better sleep.
Table of Contents – Where do we begin?
Or, you can always start at the beginning:
What is Insomnia?
Insomnia (Sleeplessness) is a disorder in which a person experiences difficulties initiating or maintaining sleep not due to time constraints. So if you’re unable to get enough sleep because you’re just too busy, that will not make you officially an insomniac. Also, if you feel perfectly well the following day, you will most likely not be regarded as suffering from Insomnia Disorder; to establish this diagnosis, a daytime impairment must be there as well (e.g., sleepiness, fatigue, cognitive memory problems.) However, you will still benefit from reading this article as the suggestions I will present below are relevant and would be tremendously helpful to anyone who is unsatisfied with the quality of their sleep.
How many people suffer from insomnia?
It is estimated that between 10% to 22% of the adult general population (more women than men) suffer from insomnia, depending on how broad the definition is. Even more than 20% of people (closer to 50%!) say that they are not happy with the quality of their sleep and/or suffer from at least one symptom of insomnia.
And these percentages seem to be going up over time.
Risks of Insomnia
Among other things, suffering from insomnia may increase your chances of becoming depressed or start abusing substances, such as alcohol and sleeping meds.
Causes of Insomnia
Insomnia may be caused by medical conditions, substance abuse or by other sleep or mental disorders (Co-morbid/Secondary Insomnia), or it can occur independently (Primary Insomnia).
Co-morbid/Secondary Insomnia are associated with and may be caused by many medical conditions (such as chronic pain), sleep and psychiatric disorders (such as depression), substance abuse (including alcohol, drugs and medications such as stimulants, corticosteroids, blood pressure meds and anti-depressants.)
Escitalopram, a very popular anti-depressant sold under the brand names Cipralex and Lexapro, may cause insomnia as a side effect in up to 12% of the people taking using it.
The causes of primary insomnia vary and may generally be classified to short-term vs. chronic insomnia:
Short-term/episodic/acute insomnia – You are able to recognize the stressor causing your sleeplessness. When you adapt to the stressor or its power is reduced, the insomnia goes away. The whole thing shouldn’t last more than 3 months.
Chronic/Persistent Insomnia lasts at least 3 months (and is known as Recurrent Insomnia if it occurs more than once per year). Its causes may vary based on the subtype of the disorder, which include:
- Psychophysiological insomnia – With high arousal during the day, you are not getting enough exercise during the day, are not able to relax at night, and oftentimes experience anxiety due to your inability to sleep.
- Paradoxical insomnia – You don’t feel as tired as you should have been with the little sleep you have been getting.
- Idiopathic insomnia – You have suffered from insomnia since you were a child.
- Poor sleep hygiene – You may be hurting your sleep by lifestyle choices, such as sleeping in a noisy environment or a non-darkened room, going to sleep at different hours every day, napping, using alcohol, caffeine or nicotine before going to sleep or not taking the time to wind down and relax before bedtime. This is the easiest type of insomnia to cure. Just a few lifestyle changes may be all that’s needed in this case.
Insomnia Medications (Helpful Drugs)
Several types of medications are used for the treatment of insomnia. Most of them require a prescription and therefore can only be used by people who are diagnosed as suffering from chronic insomnia.
What are the requirements for an official diagnosis of chronic insomnia?
- Insomnia which lasts at least 3 months
- Minimum 3 nights per week
- The condition is causing distress or interferes with the patient’s functioning the following day
It is estimated that only about 10% of the population suffer from chronic insomnia disorder. What about the other 12-40%? What if you suffer from occasional insomnia? Some medications may still help, but it would be more difficult to get a prescription. If you are unable to get a prescription, then you can use an over-the-counter drug, such as melatonin or an anti-histamine, or even better, resort to a non-pharmacological treatment (see below.)
Benzodiazepines – First-line Hypnotics
The safest and most effective class of drugs for the treatment of both daytime and nighttime symptoms of insomnia are benzodiazepines (BZDs), commonly known as benzos. This name is a bit misleading though; while not all of these drugs are benzodiazepines themselves (nonbenzodiazepines which act like benzodiazepines are known as BzRAs, or benzodiazepine receptor agonsits), they all act in the same way by binding to benzodiazepine receptors in the brain and increasing the activity of an inhibitory neurotransmitter known as GABA.
Since benzodiazepines exert their effect by increasing the efficacy of GABA, might GABA supplements be helpful?
Probably not. At least there’s currently no evidence that GABA can even cross the blood-brain barrier and reach the brain.
FDA Approved Benzodiazepines (BZDs)
- Estazolam (ProSom)
- Flurazepam (Dalmane)
- Temazepam (Restoril)
- Triazolam (Halcion)
- Quazepam (Doral)
FDA Approved Benzodiazepine Receptor Agonists (BzRAs)
- Eszopiclone (Lunesta)
- Zaleplon (Sonata)
- Zolpidem (Ambien, AmbienCR, Edluar, Intermezzo, Zolpimist)
The main difference between the different benzos is in their duration of action. Based on your idiosyncratic needs, your physician will choose one of these drugs for you, as well as a proper dose.
Benefits of Benzos
- Most of these drugs will make people suffering from chronic insomnia fall asleep faster and increase their total sleep time. They may reduce the number of nightly awakenings and improve the quality of sleep.
- There’s usually no problem of drug tolerance, meaning a higher dose of benzos is not required once the patient gets used to the drug.
- They can help even when the insomnia is a symptom of other disorders (secondary insomnia), such as rheumatoid arthritis, depression, anxiety, and chronic pain.
- Most people who take them report improvement in sleep quality and are generally very satisfied with the drugs.
- Benzodiazepines also improve daytime consequences of insomnia, such as alertness, ability to function and a physical sense of well-being.
- Substance abuse almost never happens with this type of drugs.
Sounds great? Hold your horses… There are some downsides to using benzodiazepines.
Benzos – The negatives
While benzodiazepines are very safe, in rare cases mild adverse reactions may occur, such as amnesia and residual drowsiness, but these are usually dependent on dose and duration of action so they can often be avoided by adjusting the dose and/or type of benzodiazepine used. You definitely don’t want to be sleepy while driving in the morning, which can happen when the nightly dose is too high. To tackle this problem, your doctor will most likely start you up with a very small dose and then increase it gradually as needed.
Contraindications (do not use if you suffer from…) – severe COPD (due to a risk of respiratory failure); obstructive sleep apnea; substance abuse disorder (or a history of drug and/or alcohol abuse); advanced liver disease. It is advised not to drink alcohol while taking benzos. Do not use while pregnant or if it is not possible for you to sleep for at least 5 hours from when you take the drug.
Another problem with benzodiazepines occurs when patients stop taking them. The discontinuation of the drug causes rebound insomnia so your insomnia might get even worse than it was for a couple of days. This phenomena can be evaded by using longer acting benzos or gradually reducing the dose until stopping.
Withdrawal – after long-term use of benzodiazepines, patients may also experience a withdrawal syndrome which consists of unpleasant symptoms, such as irritability, increased tension and anxiety, panic attacks, hand tremor, shaking, sweating and more, which may last up to a few weeks.
Older adults may have an elevated risk for falling when using benzodiazepines. It may also increase their risk for cognitive decline, including Alzheimer’s dementia.
Finally, there are some conditions associated with benzodiazepine use but have not been proven to be caused by it, such as somnambulism (sleepwalking) and even an increased mortality rate.
Benzodiazepines are recommended for people whose insomnia is either causing significant distress or may have deleterious effects on their health and/or safety. Their effects are immediate, while curing insomnia through non-pharmacological methods may take up to 2 months or even more.
A good idea might therefore be to use the drug (if your doctor prescribed it for you), starting at the lowest dose and revving it up (according to your doctor’s instructions) until the distress is gone and you can function, at least close to normal. Then, use a non-pharmacologic method to cure your insomnia while gradually weaning off the drugs.
Other Drugs for Insomnia
While benzodiazepines are considered first-line pharmacotherapy for insomnia, other drugs may sometimes be prescribed, depending on different factors, which we will consider next.
Melatonin is mostly indicated for children who suffer from insomnia, including those with neurodevelopmental disorders, such as ASD (Autism spectrum disorder), as well as for older adults with Alzheimer dementia. With no risk for abuse, melatonin may also be a great choice for people with a history of substance abuse.
In some countries, including the United States, melatonin is available as an over-the-counter medication, therefore no prescription is usually required. Doses are typically 2-6 mg.
While melatonin is available also in a delayed release preparation, it mostly affects sleep onset rather than sleep maintenance and duration.
Side effects include headaches. Melatonin is not recommended for men and women who are trying to conceive since it may cause a temporary disruption of ovulation and sperm generation.
Two pistachio nuts, or a handful of tart cherries, may provide a clinically significant dose of melatonin minus the side effects.
Ramelteon (Rozerem) – Melatonin Receptor Agonist
Ramelteon works in a similar way as melatonin and is used for treating sleep-onset insomnia in people suffering from COPD (a condition which is regarded a contraindication for the use of benzodiazepines, as mentioned above) and sleep disordered breathing (SDB) since unlike benzos, ramelteon does not exacerbate breathing problems.
Like melatonin, it is taken before bed. Dose is 8 mg. Its main effects are a shorter sleep latency (takes less time to fall asleep) as well as possibly increasing total sleep time.
At the normal dose, side effects include headache, dizziness, fatigue and nausea. The only contraindication with ramelteon is severe liver failure. Like melatonin, there is no risk of abuse so it can be used even with people who have a history of substance abuse.
Antihistamines are medications which are capable of reducing or even stopping an allergic reaction. They are used to treat patients who suffer from allergies as well as upper respiratory infections. Some of them, specifically diphenhydramine (Benadryl) and doxylamine (Unisom), can also be used to treat insomnia. They are over-the-counter medications, so they do not require a prescription. In fact, diphenhydramine is the active ingredient in most OTC sleep aids. It has a long half-life, which means that you may still feel groggy or drowsy after 8-9 hours of taking the drug.
Adverse effects may include dizziness, psychomotor/cognitive impairment, dry mouth, blurred vision, constipation, urine retention and weight gain. Antihistamines have no abuse potential.
Diphenhydramine and doxylamine should not be used by people suffering from asthma, COPD and severe liver disease.
Antidepressant medications are used to prevent or relieve depression and elevate mood. However, in much lower doses they are sometimes also used to treat insomnia.
Tricyclic antidepressants, such as amitriptyline (Elavil), doxepin (Silenor) and trimipramine (Surmontil), are used to treat insomnia when it is accompanied by major depressive disorder (MDD), chronic pain and/or anxiety and in individuals with a history of substance abuse (since they have a low abuse potential).
Doxepin is also used for early morning awakenings and could be beneficial when insomnia is accompanied by allergies. Do not combine Doxepin with MAOIs (a type of anti-depressant, but also present in plants such as Banisteriopsis caapi, Syrian Rue, and Passionflower).
While trimipramine will improve the quality of sleep without making you fall asleep faster, doxepin improves sleep quality, daytime well-being as well as sleep onset and maintenance.
Potential side effects include daytime sedation, dizziness, weight gain, postural hypotension, dry mouth, blurred vision, constipation and urinary retention, but they are more common in the higher doses given to patients with depression than with the lower doses used for insomnia. Tricyclic antidepressants should not be used by people with a history of heart disease, seizure disorder, bipolar disorder and liver disease.
Trazodone (Oleptro) is another antidepressant which can be used to treat insomnia in people with a history of substance abuse (since it doesn’t appear to have an abuse potential). It helps both with falling asleep and maintaining sleep. Potential side effects include daytime sedation and drowsiness, fatigue, cardiac arrhythmias, dizziness, headache, dry mouth, blurred vision, hypotension and light-headedness, weight gain, anxiety and rarely priapism (which may lead to impotence; if you are a man, you might want to try a different drug). It’s contraindicated for people with liver or kidney disease and for those suffering from bipolar disorder.
Mirtazapine (Remeron) is also used for major depressive disorder and it can be useful in cases where the patient is also suffering from sleep disordered breathing (e.g., obstructive sleep apnea) in addition to insomnia and for people with a history of substance abuse. Its effects may include falling asleep faster and improved sleep maintenance. Potential side effects include daytime sedation, dry mouth, increased appetite, weight gain and constipation. Mirtazapine is not to be used by patients who are overweight or those with bipolar disorder or with liver/kidney disease.
Suvorexant (Belsomra) – Orexin Receptor Agonist
Suvorexant is effective for preventing early morning awakenings and also makes it easier to fall asleep. It’s used for people with mild to moderate COPD as well as for people who may require a long-term treatment with medication (as it doesn’t appear to cause dependence). Potential side effects may include daytime sedation. Narcoleptics and people with a history of substance abuse should not use this drug.
While antipsychotic drugs, namely olanzapine (Zyprexa) and quetiapine (Seroquel), are normally used to treat psychotic disorders such as schizophrenia as well as other mental disorders such as anxiety, mania and depression, in some cases they are used to treat insomnia, albeit in much lower doses. Olanzapine is capable of improving duration of sleep, while quetiapine can potentially reduce the time it takes patients fall asleep.
There’s no abuse potential with antipsychotics so they can be used in patients with a history of substance abuse, however side effects may include cognitive impairment, dry mouth, postural hypotension, weight gain, glucose intolerance and a higher risk of death in people suffering from dementia. They are contraindicated in patients who are overweight or suffering from heart or liver disease.
Anticonvulsants are a type of drug that is used to treat seizures caused by epilepsy. Some of them are also useful for pain, periodic limb movement disorder, restless legs syndrome (RLS), bipolar disorder and insomnia. Gabapentin (Neurontin), which is also used for alcohol dependence and withdrawal, and pregabalin (Lyrica), which is also given to patients with fibromyalgia, are great examples.
There may be a potential for abuse though with pregabalin. Side effects of both drugs may include sedation and dizziness. They should not be used by people with kidney disease.
Tiagabine (Gabitril) is another drug used for partial seizures. Its main effects are to increase the deeper levels of sleep (slow wave sleep), but it won’t make you fall asleep faster or improve your sleep maintenance. Side effects may include sedation, dizziness, nausea and possibly seizures. It may be inappropriate in patients with liver disease.
Chloral hydrate is mostly used by patients who are elderly or by older adults with mild dementia. It has a high abuse and dependence potential, may damage the liver and kidneys and an overdose can kill. Side effects include nausea, diarrhea, psychomotor impairment and parasomnias. In short, this is a drug you might want to avoid.
Sodium oxybate (Xyrem)
Sodium oxybate is normally used to treat fibromyalgia and narcolepsy (specifically cataplexy and daytime sleepiness). Its effect is rather short lasting, thus a second dose is usually taken in the middle of the night.
It is useful for both shortening the amount of time it takes to fall asleep and improving sleep maintenance. Side effects may include headache, nausea, vomiting, excess salivation, parasomnia and amnesia. It also has an abuse and dependence potential. An overdose can lead to coma and delirium. Avoid if you suffer from COPD or respiratory problems including sleep disordered breathing.
Best Drug by Main Symptom
Sleep-onset Insomnia – zaleplon, triazolam, ramelteon
Sleep-maintenance insomnia – suvorexant, doxepin
Sleep-onset + sleep-maintenance – eszopiclone, zolpidem, temazepam
Best Drug by Comorbid Condition (Insomnia + …)
While benzodiazepines are regarded as first line therapy for insomnia, some people, such as those with a substance abuse history, those who do not respond to or tolerate benzos, or those who suffer from one of the below conditions, may benefit from using other types of drugs.
Alcohol dependence or withdrawal / a history of substance abuse
When one drug for both conditions is desired (otherwise use eszopiclone, zolpidem or clonazepam with non-sleep inducing antidepressants):
- Sodium oxybate
- Sodium oxybate
Neurodevelopmental disorders in children
When a single drug is preferred for both pain and insomnia:
Partial seizures (epilepsy)
Psychosis / schizophrenia / bipolar disorder / mania / hypomania
Restless legs syndrome / periodic leg movement disorder
Sleep Disordered Breathing (SDB)
Upper respiratory infections
The main problem with the pharmacological approach to treating insomnia is that it consists of treating the symptoms; you’re not curing the underlying cause and will therefore need to keep taking the medication to maintain its effects.
Also, there’s the problem of liver/kidney damage which can happen with many medications, even safe ones such as benzodiazepines.
For example, recently there was a case of a Japanese man who had been taking lorazepam (Ativan), one of the most popular benzos, for 5 months until he was admitted to a hospital suffering from drug-induced liver injury.
Zolpidem, another popular benzodiazepine used to induce and maintain sleep, is increasingly reported to have an abuse potential. One particular case study published recently in the Journal of Clinical Sleep Medicine (2018) reported that a 29-year-old man who was prescribed 300 to 1,200 mg/day of zolpidem, but started abusing it to feel energetic during the day. Unfortunately, he got into a car accident, apparently because high doses of the medicine may cause a subjective feeling of wakefulness with an underlying excessive daytime sleepiness, which the patient is often unaware of.
When using hypnotics, you should steer away from alcohol, and that may also be a problem for some people. They might also exacerbate any existing tendencies of complex behaviors during sleep, such as sleep driving, sleepwalking and sleep eating.
If you don’t want to be dependent on drugs, you should probably resort to a non-pharmacologic treatment, which will be the focus of the rest of this article.
Some cognitive and behavioral therapeutic methods are highly effective in improving sleep (80% of patients) and curing insomnia (in approximately 50% of patients), even in patients who suffer from conditions such as depression, cancer, and chronic pain in addition to insomnia, as well in older adults and chronic users of hypnotics.
Issues emphasized in this kind of psychological therapy include:
- sleep-scheduling issues
- poor sleep habits
- excessive worrying
- erroneous beliefs about sleep
Since they are not less effective than pharmacological treatments, cognitive-behavioral treatments should be considered first-line therapy and treatment of choice for insomnia (although they rarely are in clinical practice.)
What methods do sleep therapists use?
- Sleep restriction – a method to increase the duration of sleep by restricting the time spent in bed to just the actual sleeping time, gradually increasing that sleeping window until optimal sleep duration is achieved.
- Stimulus control – Stimulus control involves practices such as to only spend time in bed when sleepy. If unable to sleep, don’t just wait there waiting for sleep to come; get out of bed and do something else. Napping is not allowed, a consistent wake up time is maintained and the bedroom is only used for sleep. Yes, this means not watching TV or reading in your bedroom.
- Relaxation – requires daily practice of practices such as biofeedback, meditation including yoga and mindfulness-based stress reduction (MBSR; a scientifically standardized practice of mindfulness meditation), breathing exercises, progressive muscle relaxation and guided imagery over a period of at least 2-4 weeks. This approach is especially helpful for people who suffer from anxiety or stress. Even just taking a hot bath before bed may be helpful.
- Cognitive therapy – a process in which a therapist helps their patients reduce excessive worry about sleep and change their beliefs, attitude and the way they think about sleep and their condition through conversation and behavioral experiments.
- Sleep hygiene education – involves educating the patient about health and environment factors that influence sleep and how they can modified in order to improve the quality of sleep. Sleep hygiene guidelines includes maintaining a cool room temperature, winding down before bedtime, avoiding stimulating activities and substances, naps and alcohol, establishing a fixed sleep schedule, etc.
- Paradoxical intention – confronting the fear of staying awake in an effort to eliminate the anxiety surrounding the patient’s ability to fall asleep.
CBT-I (Cognitive-Behavioral Therapy for Insomnia) involves a combination of cognitive and behavioral methods. For example, a CBT therapist may focus on sleep restriction and stimulus control as well as cognitive therapy and sleep hygiene education. There are also purely behavioral approaches which leave out the cognitive component.
Self-guided Internet-based approaches as well as using printed materials/DVDs are available (and effective) for people who are unable to physically visit a therapist. Group therapy is also helpful (and cheaper.)
How long will it take to overcome insomnia with CBT?
The first stage in which most changes take place lasts for 6-8 weeks, during which patients spend around 4-6 hours with their therapist. An example schedule could consist of a weekly one hour session for 6 weeks or half an hour per week for 2 months. Afterwards, follow-ups may be scheduled based on the specific needs of the patient.
While CBT seems to be the best approach for treating chronic insomnia (approximately 70-80% of patients will benefit from it), there’s no evidence that it works for acute insomnia.
CBT-I works well also in the treatment of secondary insomnia, such as that which often accompanies fibromyalgia.
Side Effects of Cognitive Behavioral Therapy
If CBT is so great, then why are there still people suffering from insomnia? Well, on the one hand, there is the interest of the pharmaceutical companies, which will do everything in their power to keep pushing their merchandise to patients. And they are extremely powerful, especially over doctors. By providing a lot of funding to medical research and even sponsoring physicians, they ensure that sleep doctors keep prescribing medicine over non-pharmacological treatments.
But then there are the insurance companies, which are also quite powerful. And their interest is to push CBT. Why? Because it’s so much cheaper than medicine and other long-term treatments for insomnia. CBT is supposed to cure insomnia. Fast. And a fast treatment means a less costly alternative to psychotherapies which may sometimes last months and years or medications, which require taking them forever since they are only treat the symptoms and not the underlying condition.
Unfortunately, there are both unwanted events (consequences of inadequate treatment) and side effects (negative reactions) in cognitive behavioral therapy which should be taken in consideration when deciding on a course of treatment for sleeplessness.
In a study published in Cognitive Therapy and Research journal (2018), hundred CBT therapists were interviewed in order to determine whether there are side effects and unwanted events involved in this kind of therapy and what they are. 372 unwanted events and side effects were reported, the most common of them being:
- negative well-being/distress (27% of patients)
- worsening of symptoms (9% of patients)
- strains in family relations (6% of patients)
21% of patients suffered from severe or very severe, and 5% from persistent side effects.
While unwanted events can be prevented by choosing a qualified therapist (which is not so easy nowadays as the high efficacy of this treatment led to a large number of CBT therapists with not enough experience and inadequate training), side effects are unavoidable and are common even in well-delivered cognitive behavioral therapy.
A meta-analysis of randomized controlled trials examined the effect of mindfulness-based interventions (MBIs) on insomnia. The results, published in the Behavioral Sleep Medicine journal (2018), suggest that MBIs appear to be effective in the treatment of insomnia, however there is a lack of studies which examine long-term effects of this treatment.
I’d like to suggest that perhaps a better way to think about mindfulness would be that it shouldn’t be taken as a time-limited intervention but rather as an attitude that ought to be cultivated throughout the lifetime of both insomniacs and people who don’t suffer from insomnia.
Other Non-Drug Approaches for Treating Insomnia
Complementary/alternative therapies are sometimes used in the treatment of chronic insomnia. Some examples: acupuncture, tai chi, hypnosis, exercise and CES (cranial electrotherapy stimulation; also known as electrosleep therapy).
But how effective are they?
Acupuncture / Chinese Medicine
Acupuncture is a method used by practitioners of Chinese and Japanese medicine, in which thin needles are inserted into the body at various points to effect physiological changes.
Several studies put acupuncture (and a few of its variants, including acupressure, auricular magnetic and seed therapy and transcutaneous electrical acupoint) to the test for treating chronic insomnia. There were some positive results, such as a general improvement in sleep quality, but no change in time it takes to fall asleep and in total sleep duration.
Another review of the literature found that acupuncture was more effective than benzodiazepines for treating insomnia and improving sleep.
Both reviews conclude that due to methodological problems, the positive results are not conclusive. Currently, there doesn’t seem to be enough evidence justifying treating insomnia with acupuncture unless the insomnia is secondary to health problems acupuncture does improve, such as chronic low-back pain.
Auricular acupuncture is a sub-type of acupuncture focusing on the ear. A randomized clinical trial was conducted and its results published in the Medical Acupuncture journal (2018). The improvement in the Insomnia Severity score of patients receiving ear acupuncture was better than that of those who received the usual care. The researchers concluded that “[w]ith the heightened focus on the opioid crisis in the United States, this easy-to-administer protocol may be an option for treating military beneficiaries who have chronic pain and insomnia.”
Chinese doctors oftentimes also use herbal medicine to treat insomnia. The most commonly used herb appears to be seeds of a type of Jujube fruit, specifically Ziziphi spinosae (suan zao ren). The herbal formulae which are frequently prescribed include Wen dan tang, Suan zao ren tang, Ban xia shu mi tang and Gui pi tang. A review of randomized controlled trials published in Sleep Medicine Review (2012), which put these Chinese herbal medications (CHM) to the test for treatment of insomnia, concluded that “the current evidence is insufficient to support the efficacy of CHM for insomnia […] Further studies with a double-blind placebo-controlled design are needed to accurately determine the benefits and risks of CHM for insomnia.”
Yoga, Tai Chi
Yoga is a group of physical, mental and spiritual practices. Nowadays, when we say yoga, we usually refer to the physical aspects, such as stretching and breathing. Some studies found that yoga improves sleep quality and reduces symptoms of insomnia secondary to chronic medical conditions. One study found that Kundalini yoga, which stresses breathwork and meditation, improved total sleep time and sleep quality in people suffering from insomnia disorder. Unfortunately, one small study is not enough evidence and so treating insomnia with yoga is currently not warranted.
Tai chi is a Chinese meditative martial art practiced mainly for its health benefits. It can apparently improve sleep in sedentary older adults with moderate sleep disturbance. It may also be great for COPD, depression, fibromyalgia, and improve sleep in general.
But can it cure insomnia?
While they may make some generally healthy people sleep better, there’s no evidence that either Tai chi or yoga can cure insomnia. Admittedly, not much research has been done.
“Music seems to help the pain…” but can it help people with insomnia?
A review of the literature attempted to answer this question by going through 20 studies which used music therapy for people with primary insomnia.
Music-associated relaxation was found to be effective in terms of overall sleep quality, efficiency and latency (time to fall asleep).
The authors include that when “considering the efficacy, music intervention seemed to offer clear advantages for adults with primary insomnia.”
Hypnosis / Hypnotherapy / Autogenic Training / Guided Imagery
Hypnotherapy is a type of complementary and alternative medicine which uses hypnosis to help with a variety of problems.
Can it help you if you’re suffering from insomnia?
Electrosleep therapy (cranial electrotherapy stimulation; CES)
In cranial electrotherapy stimulation (CES; also known as electrosleep therapy, cranial-electro stimulation and transcranial electrotherapy), a small, pulsed, alternating current is delivered to the brain via electrodes on the head.
A systematic review of the literature found that while CES may be slightly beneficial for patients suffering from anxiety and depression, it doesn’t seem to improve insomnia symptoms.
Herbal Remedies for Insomnia
Is Cannabis Helpful for Insomnia?
As cannabis is becoming more and more legitimate in more and more US states and EU countries, advocates of using this drug for alleviating sleep problems abound.
Cannabis, also known as marijuana, is a mild sedative/depressant at low doses and an hallucinogen at higher doses, which is commonly abused. Many people with a substance abuse problem complain of insomnia, and cannabis withdrawal, which may occur in about 50% of cannabis users, sometimes involves sleep disturbance as well as anxiety and depression.
However, some people claim that cannabis helps them sleep better.
What are the effects of marijuana on sleep?
First, it should be mentioned that the cannabis plant contains many cannabinoids. Two of the most commonly known cannabinoids are delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD).
The THC component of marijuana may reduce REM sleep and increase total sleep time and slow wave sleep (deep, restorative sleep). However, when taken over a long period of time (every day for one week), it may suppress slow wave sleep. The data suggests that a low dose of THC (4-20 mg) may be used every once in a while for sleep support, but not every night. Higher doses of THC (50 mg and above) do not seem to be helpful for sleep. On the contrary, they may reduce both REM sleep and SWS.
Side effects of THC consumption may include psychosis and anxiety.
The only condition for which cannabis seems to help is in insomnia which is accompanied or caused by pain, especially neuropathic pain, and in people suffering from PTSD.
- The severity of symptoms was reduced by 4.5 points (on a 0-10 scale).
- Use of pipes and vaporizers was associated with greater relief than joints.
- Using a vaporizer was associated with less negative effects.
- CBD was associated with greater symptom relief than THC.
- Cannabis sativa was associated with more negative side effects than cannabis indica or hybrid strains.
Another study concluded that CBD may hold benefits for insomniacs and that while THC may make you fall asleep quicker, it could impair sleep quality in the long run.
Passiflora incarnata (a.k.a Passionflower) acts as an nervine (calms the nerves) and hypnotic (sleep inducing). It has sedative and soothing properties and is used to treat insomnia, specifically when it’s an acute condition and not chronic. Meaning, if every once in a while you experience insomnia, Passionflower may help. And unlike medications, it does not cause hangover + it has other useful properties, for example, it is anti-inflammatory.
Keep in mind that you should probably not take it in addition to other sleep inducing medications, blood-thinning drugs or MAOIs (monoamine oxidase inhibitors) such as selegiline and some anti-depressants. Do not use while pregnant (it contains alkaloids). Always a good idea to consult with your doctor before using such powerful herbs.
Dosage: 0.25-2 grams dried herb infused in hot water (10-15 minutes) before bedtime. Capsules/tablets and tinctures are also available.
There are scientific studies that put this plant to the test and found that it indeed works for inducing sleep. See this one for example from Sleep Science Journal. Passiflora incarnata was found to increase total sleep time and slow wave sleep. Time spent awake and REM sleep were reduced.
Valeriana officinalis, a plant native to Europe and Asia, has been used to treat insomnia for centuries. Dosage ranges from 400-900 mg per day. While some studies found it is effective, many others didn’t, thus there’s no scientific confirmation it actually works. However, with little to no side effects (when used together with Skullcup, it may cause hepatitis) and no abuse potential, it may not hurt to try it, especially if you’re only suffering from mild insomnia, do not want to take pharmaceutical drugs and do not suffer from liver disease.
Dosage: 2 teaspoons dried herb per cup of boiling water (cover the cup to avoid essential oil evaporation). Tinctures are oftentimes used.
Do however consult with your doctor before using valerian or other OTC sleep aids, keeping in mind that the official medical consensus is that they are not recommended.
As with Passionflower, scientific studies are yet to demonstrate a positive effect on insomnia disorder.
Other Helpful Plants
In addition to Passionflower and Valerian, which are the most effective herbs for insomnia, there are other plants which are known to have a strong hypnotic, sleep-inducing effect, such as Eschscholzia californica (California poppy), Humulus lupulus (hops), Lactuca virosa (wild lettuce), Piper methysticum (kava kava), Aloysia citriodora Palau (lemon verbena), and Polygonatum sibiricum (King Solomon’s-seal).
A 2020 randomized double-blind placebo-controlled study found that a syrup extracted from Viola odorata improves insomnia symptoms among sufferers of depression and OCD.
How to Cure Insomnia? My Approach – Paleolithic Sleep
In most cases, insomnia is not a disease. A disease is something that happens to us. Insomnia is often something we do to ourselves, a lifestyle.
Insomnia is a certain way of life. It’s the modern way of life. In our nature, we should not be sitting in front of a computer the whole day. We need to walk, run and do physical work for at least 8 hours every day. When we rest too much during the day, we most likely will get less rest during the night when we’re sleeping. There’s no need. We already rested during the day! So the body and mind are restless during the night.
Animals do not experience insomnia in nature. Horses which are kept in stables suffer from severe insomnia and a strong drowsiness during the daytime as well as exhibit symptoms, such as sleepwalking and night terrors.
Natural humans most likely did not experience insomnia.
For thousands, nay more than a quarter million years, we’ve been living like that. The men were out all day hunting. The women were taking care of the children and foraging. At least 8 hours per day we used to work. Even when farming was invented, most of us still spent much of our time working in the fields, cutting wood, carrying water, etc. The sedentary civilization is completely new. Not more than a few hundreds of years.
Modern humans experience insomnia because as we grow richer as a society, some people have the luxury of not exerting themselves at all. The poor people do all the hard labor. And in the future computers and robotics might even replace those last manual laborers. Then we will all be insomniacs. Maybe sleep will disappear altogether. It will not be needed anymore. But we’re not there yet. Our body is still the body of an animal. And we need to act as one, at least in regarding to sleep.
My approach therefore might be likened to those nutritionists who advocate the Paleolithic diet. I personally do not recommend this diet for many reasons including that industrialized animal products are generally of very low quality in comparison to the natural, game meats the paleolithic people used to eat. We also work out less than ancient man and eat much less fiber.
But this article is not about sleep nutrition. Let me just say here that the best thing you can do for your sleep for a nutritional perspective would be to have normal weight. Obesity in particular may cause sleep disorders. The easiest way to make sure you have a healthy weight is to follow a whole food plant-based diet.
Oh, and eating schedule matters too. You should pay attention not just to what you eat, but also when you eat it. Briefly, try to take most of your daily calories during the daytime. Your final meal of the day should be at least 4 hours before bedtime to allow ample time to digest the food properly.
Paleolithic activity and sleep is the cure for insomnia I would like to share with you. Exert yourself during the daytime when the sun is shining as if you were a stone age human, and at night you will be able to sleep like one.
The way our body works is very simple. Anyone who has kids knows this. If you don’t tire your kids enough during the day, they will have difficulties falling asleep. And the same goes for adults. If you work hard for 8 hours during the daytime, when it gets dark your sleep hormones will naturally lead you to sleep. But we rest during most of the day and when night comes, we turn on bright lights and screens and ingest stimulants, such as caffeine and nicotine, and then we wonder why we can’t sleep?
This fact becomes even clearer when we notice how insomnia rates are continuously going up as living in this world becomes easier and easier for most people, or when we compare insomnia rates in rich vs. poor countries. In India, Africa and Indonesia insomnia is rare (if we control for disease, such as HIV, which are more common in Africa, and cause insomnia. But when people from Africa move to the US, their insomnia rates become similar to those of Americans. Maybe even worse, as there seems to be a genetic variability in the need for exercise. The more exercise a person’s genetics require, the higher the chances that the lack of exercise will cause sleeplessness for them.
The pathophysiology of insomnia (its disordered physiological processes) strengthens and further elucidates this theory. It is currently believed that underlying insomnia is a perpetual state of hyperarousal, constantly activating the sufferer’s flight or fight response, which requires physical action to relieve, without which high stress and wakefulness-promoting substances in the brain will interfere with sleep. The more hyperarousal one experiences, the more exercise they will need in order to be able to sleep at night.
As people grow older, insomnia becomes more prevalent, which perhaps can be explained by the fact that older people in general do less work. University students suffer more from insomnia. Maybe it’s because they spend so much of their time sitting down, while they should be working, moving, exercising, being physically active. Women suffer more from insomnia than men. Unsurprisingly, they also get less physical activity than men.
Scientific research has started recognizing the importance of exercise to treating and preventing insomnia. In a 2020 study published in the Journal of Aging and Physical Activity, individuals who reported more physical activity had fewer insomnia symptoms. Over a period of 10 years, there was a negative correlation between insomnia and physical activity. The more physical activity the respondents reported engaging in, the less insomnia symptoms they experienced.
So the first thing I suggest for my clients is to increase the amount of active time they’re getting throughout the day and decrease time spent resting. You don’t necessarily need to exercise. Instead of hiring a gardener or a cleaning service, instead of eating out, tend your own garden, clean your house by yourself, shop for and cook food for your family and yourself.
Can’t sleep? Then forget about it. Go work out. When your body is tired enough, it will sleep. There’s no way to avoid it. But sleep cannot be forced, shouldn’t be forced.
Insomnia is your body telling you are not giving it what it needs.
How did Paleolithic people and other ancient humans sleep?
If we ignore the effect that the original paleolithic diet had on gut health (they after all ate way more fiber than we do) and therefore on sleep as well and just focus on the paleolithic sleeping habits, what can we learn from them?
There are two lifestyle elements characterizing the ancient way of sleeping:
- Wake up around sunrise. Sleep while it’s dark.
- As mentioned above, 8 hours a day of physical activity where not unusual for ancient humans.
Notice that I didn’t say that ancient people slept more hours than us. On the contrary, there’s evidence they were sleeping less, or about the same. However, less sleep may be okay if sleep is sound and occurs at the right time and under ideal conditions.
So how come these pre-industralized civilization don’t have a word for insomnia? How come they are healthier than us even though our sleep duration is not less than theirs?
Let’s go over these two elements now and see why they are so important and why we should strive to incorporate them into our lives.
Circadian Rhythms (How to sleep?)
A research paper published in Current Biology on October 15, 2015 examined the sleeping habits of three pre-industrial, hunter-gatherer societies in order to gain insight into the sleeping habits of ancient humans. Here is a summary of their findings:
- Duration of lying down to sleep was 6.9-8.5 hours with actual sleep time of 5.6-7.1 hours.
- During the winter, they slept 1 hour less than they did during the summer.
- Sleep began on average 3.3 hours after sunset.
- Sleep ended usually before sunrise.
- They always went to sleep and woke up at the same time
- Sleep period occurred during nighttime when environmental temperature was declining.
- Napping occurred on less than 7% of winter days and less than 22% of summer days
- They were exposed to light mostly during the morning, while seeking the shade around noon
The researchers conclude that “[m]imicking aspects of the natural environment might be effective in treating certain modern sleep disorders.”
Another interesting study compared two communities of historic hunter-gatherers, one with access to electric lights and another which relies solely on natural light. The community who had access to electricity slept less, went to sleep later at night and took more time to fall asleep. The researchers conclude that their study “supports the notion that access to inexpensive sources of artificial light and the ability to create artificially lit environments must have been key factors in reducing sleep in industrialized human societies.”
To understand the benefits of this Paleolithic pattern of sleeping, we need to go over some basic sleep science. There’s a natural process taking place in our body in response to environmental stimuli which naturally leads us to sleep at night.
In short, there is an organ in our brain called the suprachiasmatic nucleus (SCN), the so-called “biological clock,” which regulates behaviors, biochemical and physiological reactions which recur naturally on a 24-hour cycle. Actually, the cycle is almost 24 hours, but not exactly (it’s 24.16 hours). Cues from the environment, including light and darkness, fine tune it to the specific environment in which we live.
Melatonin accumulates in our bloodstream from near sunset until after sunrise. Light, specifically blue light which is present in sunlight as well as in the light emitted from the screens of our electronic devices suppresses melatonin. Using a computer after sunset thus increases alertness, the time it takes to fall asleep and morning sleepiness in comparison to spending the evening hours in dim light conditions, such as the light emitted by the fire our ancestors cuddled by throughout most of the existence of our species.
And if I mentioned the fire, it’s worthwhile to also briefly discuss the correlation between sleep and temperature. Research shows that a hot bath (or sitting near a fire) before sleep can help you fall asleep faster. Normally, the body temperature peaks during the early evening (6-8 pm), and then as the temperature declines, sleep occurs. We can emulate this process by exposing ourselves to external heat just before sleep, and then as the body temperature starts declining, we can ease into sleep.
Exercise (How to be awake?)
The second important element of the Paleolithic lifestyle is how we spend our daytime. As I mention above, ancient humans (and even not-so-ancient humans) were a lot more active than we are. Here I would like to describe scientific studies that focused on the relationship between exercise and insomnia.
In a study which conducted a randomized controlled trial lasting 16 weeks was published in JAMA (1997), the subjects, older adults with moderate sleep complaints, went through four 30-40 minute endurance training sessions per week, which consisted of low-impact aerobics/brisk walking at 60-75% of heart rate. They showed significant improvement in sleep quality, time it takes to fall asleep and sleep duration compared to the control group.
A study published in the Brazilian Journal of Psychiatry (2018), assessed the effects of resistance exercise on sleep in chronic insomnia patients. Moderate-intensity resistance exercise lead to significant improvement in the patients’ Insomnia Severity Index, time it takes to fall asleep, total sleep time and sleep efficiency compared with the control group.
Another study, published in the Sleep Medicine Journal (2010), found that moderate aerobic physical activity (a 16 weeks-long intervention) with sleep hygiene education was more effective in improving sleep quality, falling asleep time, sleep duration, daytime dysfunction and sleep efficiency in patients 55 years or older suffering from chronic insomnia compared to sleep hygiene education with no physical activity.
Even Zero Time Exercise, an exercise routine designed for people who spend a lot of time sitting or standing and cannot be active, was found to be beneficial and to reduce insomnia severity in comparison to sleep hygiene education.
Clearly, exercise helps insomniacs. But how much exercise is enough?
That’s very individual. If you currently suffer from insomnia and do not exercise at all, start with just fulfilling the minimum official recommendation of 20-30 minutes per day of moderate exercise (e.g., brisk walking). If you already have an exercise routine but still suffer from sleep problems, then gradually increase your workout time and intensity until your issues are resolved.
Optimally, you should try to hit at least 90 minutes per day of moderate exercise, or 40 minutes of vigorous exercise (such as jogging.)
However, for some people even that may not be enough. And of course, you should not forget the importance of a proper light and dark schedule I mentioned in the previous section to complement your exercise routine. So ideally try to get your daily exercise between sunrise and sunset, killing two birds with one stone.
Bottom Line – How I Cure Insomnia?
The course of treatment will be different for every patient. As I said, I do not cure your insomnia since insomnia is not a disorder. It’s a way of life. I can just help you to reorganize your life in way that you will become natural again, just like you were as a kid (You will “sleep like a baby…”) Just like those primitive early humans, which lived naturally, according to the body’s wisdom. When your lifestyle becomes balanced and starts accommodating your body’s needs, your insomnia will be cured.
After taking into consideration all the relevant information, it will be possible to offer you a plan that will suit you best. In general terms, the process of ridding yourself of insomnia will include the following components:
- Deciding on an optimal schedule for your everyday life, including fixed sleeping hours.
- Improving your diet – both what you eat and when you eat it.
- Designing a daily exercise routine and incorporating it into your schedule.
- Behavioral intervention/s, such as sleep-restriction, relaxation and stimulus control.
- Learning how to adhere better to sleep hygiene recommendations.
- In some cases, using drugs at least during the early phase of the treatment will be helpful.
- If your insomnia is secondary or co-morbid with a different condition, then obviously we would need to take care of that as well.
However, these are just the broad categories of treatment with plenty of flexibility within each of them.
Insomnia (Sleeplessness) FAQ
A condition plaguing the lives of far more people than one would think, insomnia can indeed be quite the thorn in one’s side, to say the least.
What is it though, what causes it, and how can you get rid of it? Can one actually die from insomnia? These are some of the questions that I answer below.
What does it mean to have insomnia?
To make it really brief and to-the-point, insomnia is the inability to get a good night’s sleep, for whatever reason.
Unlike snoring and sleep apnea (which can lead to serious complications of their own), insomnia is more than a relatively minor annoyance. It can and will prevent people from functioning optimally in their day-to-day existence.
Insomnia has several symptoms, and there are several types of insomnia.
The inability to fall asleep is its most obvious symptom. A person suffering from insomnia will also wake up several times during the night and find it extremely difficult to go back to sleep.
Feeling tired after waking up in the morning and waking up way too early, are also symptoms of insomnia.
As far as types of insomnia go, there’s straight-up insomnia, which itself is the main problem.
Secondary insomnia on the other hand is caused by some kind of other illness/condition, like heartburn, depression and asthma, and as such, it is more of a symptom, rather than the actual cause of a problem.
Depending on how long it lasts, insomnia can be short-term and long-term. The short-term variant typically lasts from one night to a week, while the long-term version can turn one’s life into hell for months on end.
What is the cause of insomnia?
The causes of this annoying and rather debilitating condition can be physical, psychological or even chemical in nature.
Life stress is one of the main triggers. Insomnia can be triggered by traumatic life events such as job-loss, the death of a family member, or even something much more trivial, such as moving.
Stress does not have to be extreme to result in insomnia though. Even mild physical/emotional discomfort can spark the problem, together with uncomfortable temperatures, noise, lighting-related problems and plain-old jet lag.
Jet lag is indeed a major cause for sleep disorders, as it really turns one’s biorhythm upside down.
As far as medication goes, we are looking at chemicals used to treat asthma, high blood pressure, depression, as well as various allergies and cold.
Regarding long-term insomnia, many of the causes are similar, though long-term stress clearly plays a more prominent role.
How can I stop my insomnia?
Prevention is the best way to altogether avoid insomnia and all the discomfort/suffering that comes with it. Prevention is also quite straightforward, and the good sleeping habits on which it is predicated are beneficial in other areas of life too.
Setting a proper schedule is the first preventive step. Going to bed at the same time every night and getting up at the same time every morning, will play right into the body’s own bio-clock.
Taking naps during the day may be tempting, and those suffering from insomnia will indeed often encounter periods of extreme drowsiness in the middle of the day, but it should be avoided at all cost.
Avoiding chemical stimulants is recommended all through the day, but the closer it gets to bedtime, the more strictly this avoidance should be observed.
The stimulant effect of caffeine is well-known and recognized, but late-evening physical exercise can elicit a rather similar effect too. Getting regular exercise at proper times through the day is highly benefic, on the other hand.
Another issue insomnia sufferers should eliminate is using the phone/various other mobile devices that emit light, right before bed. It has been proven that the light hitting the retina confuses one’s organism into “believing” it is not bedtime yet.
How do you get rid of insomnia?
Those who already suffer from the condition have no other choice but to attempt to treat it.
The good news is that short-term/occasional insomnia does not really have to be treated. It will likely “go away” on its own, provided one does indeed observe healthy sleeping habits.
Those who find that even mild forms of insomnia make it impossible for them to function properly during the day, may resort to the use of sleeping pills. Such pills always have to be described by qualified doctors/health care providers, and the rapid-onset, short-acting types are recommended. Such pills make it less likely that the user shall experience drowsiness the following day.
Some cases warrant deeper analysis, performed at a sleep center.
Long-term insomnia is usually linked to an underlying physical condition, and in such cases, this condition needs to be eliminated before considering treatment for the sleep disorder.
Sometimes behavioral therapy may be called upon too, if the sleep disorder persists past the elimination of the underlying health issue. Behavioral therapy will obviously be focused on the promotion of healthy sleeping habits, and it will take the form of sleep restriction therapy and relaxation exercises.
As with most health issues though, it needs to be kept in mind that insomnia prevention is cheaper, easier and ultimately more effective than treatment.
What is the best treatment for insomnia?
As said above, the best way to treat insomnia – once onset – is to institute drastic lifestyle changes. Such an approach is most likely to eliminate the underlying causes of the condition, thus directly treating the root of the problem and not its symptoms.
Lifestyle changes cover a wide range of tweaks, from dietary issues, to setting a sleeping schedule, sticking to it and to being more active physically. Taking naps during the day is also a major no-no.
Generally adopting a healthier way of thinking regarding every aspect of life is also a major step in the right direction. Behavioral therapy is said to reduce interrupted sleep.
Medication should be thought of as a last-ditch solution, given the potentially negative implications that it carries. Users can become dependent on sleep medication, and this is true for the elderly as well. This will result in one’s complete inability to fall asleep without the use of sleeping pills.
Besides dedicated sleeping pills, we are also looking at antidepressants here, which have a calming, soothing effect that can promote proper sleep. Nonprescription medication is also an alternative to consider, together with natural sleep remedies. There are also foods out there that cause anxiety and insomnia. Such foods have to be researched and thoroughly avoided.
What are the best foods to help with insomnia?
There are some melatonin-containing foods, which can apparently help people sleep. Melatonin is a sleep regulating hormone, naturally produced in our body.
Melatonin is destroyed when you’re exposed to light, including the light emitted from your computer screen, TV and cellular phone. Therefore, getting melatonin from food may improve sleep.
The best food sources of melatonin include pistachio nuts, goji berries, raspberries, almonds and tart cherries.
Can a person die from insomnia?
The simple answer to that would be: theoretically yes.
The truth is though that no person has been recorded to have ever died from insomnia.
To understand why this is the case, one has to understand the difference between insomnia and sleep deprivation. The two might go hand-in-hand in some cases, but they denote different conditions.
Insomnia refers to difficulty falling asleep and getting quality sleep. Sleep deprivation, on the other hand, is about getting a less than adequate amount of sleep (or, in extreme cases, none at all).
Long story short: the effects on the cognitive system of sleep deprivation are far more radical than those of insomnia.
The bottom line is though that people seem to be able to function relatively unimpeded (from the point of view of an outside observer), even when deprived of sleep for incredibly long periods of time. There is a rare disease, which – when associated with insomnia – can be fatal, but on the whole, on a practical level, it is safe to say that insomnia will not result in death, in and of itself.
How long can you go without sleep until you die?
This question is almost impossible to answer.
Though several experiments were performed in this regard, with the record-holder having logged 11 sleepless days, there is no way to know how long a human can stay awake, because in the case of extreme sleep deprivation, the very concept of “awake” becomes blurred.
A long period of sleep deprivation will induce an altered state of mind in people undergoing such experiments, allowing them to log periods of micro-sleep. Cognitive and motor functions are gradually lost, and past a certain point, people become virtually incapacitated, while remaining “awake.”
In rat studies, however, researchers have found that death would inevitably set in, following about 2 weeks of sleep deprivation. That there is certainly something to bear in mind.
Why do I keep waking up after 4 hours of sleep?
Waking up after about 4 hours of sleep is characteristic of middle-of-the-night insomnia. This type of sleep problem leaves sufferers unable to go back to sleep after waking up in the middle of the night. It usually results in next-day exhaustion, and impaired cognitive functions.
The causes behind this type of insomnia can be numerous. One of them is sleep-apnea, which can be a serious and even life-threatening condition in some cases.
Anxiety, pain, pregnancy, working in shifts, erratic sleeping patterns and the need to urinate can also be triggers for this type of sleep disorder.
Why is it so hard to go back to sleep after waking up?
Your organism is somehow tricked into becoming alert, by a series of psychological/physical/chemical triggers, as specified above. There is not much you can do about it when it occurs, other than to learn a few techniques to deal with the situation.
To remedy the problem, most specialists recommend getting out of bed and forgetting about staring at the clock. Making sure it is not too bright and getting relaxed is the next step. Progressive muscle relaxation and even biofeedback can help accomplish that.