Sample questions
Response/Notes
History of sleep problem
When did the sleep problem (e.g. insomnia) first manifest? (e.g. as a child or as an adult, or related to a particular medical problem, e.g. cancer?)
What if there is a particular event that occurred, after which the insomnia began? Was it related to a period of stress, anxiety or depression?
How long have you had difficulty sleeping?
Nature of sleep pattern
How long do you sleep for?
What time do you go to bed?
How long does it take for you to fall asleep?
What time do you wake up?
When you wake up do you feel refreshed or tired?
Do you wake during the night?
If you wake during the night, do you fall back to sleep easily?
Do you need to get up to the toilet to urinate at night? If so, how many times?
Triggers or contributing factors
Do you notice that if you do particular activities or eat particular foods, you are more likely to have a poor night’s sleep?
Do you drink coffee or tea? If so, how many cups per day? When is the last cup that you drink?
Do you drink energy drinks? If so, how many per day and at what times during the day would you drink these?
Do you read or watch television in bed?
Do you read emails or surf the internet on a tablet, laptop or phone in bed?
Do you have animals that sleep with you either in the bed or in the bedroom?
Do you drink alcohol and if so, how many standard drinks per day would you have and at what time of day would you have them?
Do you smoke? If so, how many cigarettes per day? What time is the last cigarette of the day typically?
Alleviating factors or strategies
Is there anything that you have tried that seems to contribute to a better night’s sleep?
Impact on life
How is the poor sleep impacting on you?
How does poor sleep affect your general mood?
How does it affect your ability to function at work?
Does it have any effect on driving or other activities that you might need to do as part of your work, and if so, what are these?
Comorbid conditions that may contribute to insomnia
Clinician to record as part of patient history
Assessment of Medication
A major cause of sleep disorders can be western pharmaceuticals. Drugs are known to interrupt REM sleep cycles and while it may be necessary to use medication to relieve pain symptoms that interfere with sleep, this can often create a counterproductive cycle. Alternative pain relief strategies can be explored. Prescription drugs that may cause sleep problems include: beta blockers, ACE inhibitors, antidepressants, anti-anxiety drugs, corticosteroids (including prednisolone), levodopa (anti-Parkinsonian), cough and cold preparations, thyroid hormones and others [143].
Sleep Hygiene
Tips for getting a better night’s sleep commonly focus on getting to bed earlier, changing bedroom conditions (temperature, darkness, noise), avoiding stimulants such as caffeine and alcohol, maintaining regular sleep times and managing stress. These are all important components of ‘sleep hygiene’.
Computers, tablets and mobile phones should be left out of the bedroom. Apart from the potential effects that exposure to electromagnetic frequencies might have on the brain, anything that stimulates the mind like surfing the net is not likely to be conducive to sleep. The habit of checking emails, in particular work-related emails late at night is another modern phenomenon that interferes with allowing the mind and body to relax. Phones are best left out of the bedroom.
The US National Sleep Foundation has many useful ideas about good sleep hygiene including how to set up a bedroom, positions for sleeping, etc., that may assist. These include:
Sticking to a sleep schedule: same bed time and same wake-up time
Practising a relaxing bedtime ritual
Eliminating daytime cat-naps
Exercising daily
Designing a sleep environment conducive to sleep including a cool temperature, free from noise, free from light and free from other distractions
Sleeping on a comfortable mattress and pillows [110]
Diet and Sleep
Diet can play an important role in sleep. Many of the brain chemicals necessary for good sleep can be found in specific foods. If intake is problematic there is also the possibility of obtaining these essentials in supplement form, under the guidance of an integrative medical practitioner or other health professional. Conversely there are foods that contain substances that can interfere with sleep.
Table 4.2 sets out foods that may enhance sleep which may be integrated into a Wellness Plan. Table 4.3 sets out foods that may contribute to poor sleep.
Table 4.2
Foods that enhance sleep
Food | Mechanism of action |
|---|---|
Cherries | Contain melatonin, the chemical that helps control our body’s internal clock |
Milk | Contains the amino acid tryptophan, a precursor to the brain chemical serotonin that promotes relaxation and sleep |
Complex carbohydrates such as quinoa, barley, buckwheat and whole-wheat bread | These are, in general good for sleep but it is not a great idea to binge on carbohydrates before bedtime |
Banana | Contains the natural muscle relaxants magnesium and potassium Also a source of carbohydrates |
Turkey | Contains tryptophan, a chemical that can make people feel sleepy |
Other sources of tryptophan: hummus, lentils, eggs, milk, proteins and many nuts and seeds | Contain tryptophan, a chemical that can make people feel sleepy |
Sweet potatoes | Provide sleep-promoting complex carbohydrates, and the muscle-relaxant potassium |
Table 4.3
Foods that may adversely affect sleep
Food | How it adversely affects sleep |
|---|---|
Cheeseburgers | Very high fat content. Fat stimulates the production of stomach acid which can cause oesophageal reflux (heartburn) |
Alcohol, including wine [143] | Metabolises quickly and can cause person to wake multiple times during the night (reduces REM sleep, and in long-term users can cause difficulty falling asleep). Also increases propensity to snore |
Coffee and teas [143] | Contains caffeine, a central nervous system stimulant |
Energy drinks | Very high in caffeine. They are best avoided later in the day or, even better, avoided completely |
Soft drink | Contains high amounts of sugar, caffeine and the preservative sodium benzoate and other chemicals that can aggravate the gastrointestinal tract and promote acid reflux |
Heavily spiced foods | Can keep people awake at night, especially if the spices contribute to heartburn |
Posture and Sleep
Many patients who are overweight suffer from sleep disordered breathing [188]. Population studies have shown an increase in prevalence with increased body mass index and neck girth, and clinical studies of weight loss support a causal association [188]. Changes in posture during sleep have been found to improve sleep apnoea. In severely affected patients with obstructive sleep apnoea, upper body elevation and to a smaller extent, lateral positioning, have been found to significantly improve upper airway stability during sleep [114].
Exercise and Sleep Promotion
Many studies show exercise promotes better sleep. Regular physical exercise may promote relaxation and raise core body temperature in ways that are beneficial to initiating and maintaining sleep.
The US National Sleep Foundation’s [111] Sleep in America Poll: Exercise and Sleep provides a very detailed summary of the benefits of exercise in relation to sleep promotion. In this survey of 1000 people, participants were subcategorised into four activity levels: vigorous (activities that require hard physical effort, e.g. running, cycling, swimming, competitive sports), moderate (activities that require more effort than normal, e.g. yoga, tai chi, weight lifting), light activity (walking) and no activity. The results clearly demonstrated the positive benefits of exercise, in particular, vigorous exercise [111]. Key findings are set out in Table 4.4.
Table 4.4
Key findings of the US National Sleep Foundation’s [111] sleep in America Poll: exercise and sleep
• The percentage of those who exercise vigorously, moderately or lightly who report either very good of fairly good overall sleep quality was 83%, 77% and 76% respectively, whilst only 56% of non-exercisers report very good or fairly good sleep quality |
• The average amount of hours slept during a week day was similar across all four categories (and was just under 7 h) |
• Exercisers were significantly more likely than non-exercisers to report that their sleep needs are being met on workdays (vigorous 70%, moderate 69% and light 68% vs. no activity 53%) |
• Exercisers were significantly more likely to perceive their quality of sleep to be better on days they exercise compared with non-exercisers (vigorous 62%, moderate 54% and light 49% vs. no activity 28%), and regardless of exercise level, around half perceive that their quality of sleep improves on the days they exercise |
• Vigorous exercisers report the best sleep: they report the largest proportion of very good sleep quality and report the largest proportion of satisfaction with the amount of sleep they actually get compared to the amount of sleep they report needing |
• Overall vigorous exercisers had fewer sleep problems (waking during the night, waking up feeling unrefreshed, difficulty falling asleep, waking up early and having difficulty getting back to sleep) in the past two weeks than the other subcategories. The proportion of non-exercisers reporting the first three of these aforelisted sleep problems was significantly greater than the proportion of vigorous exercisers |
• The proportion of vigorous exercisers (50%) reporting no problem with maintaining enthusiasm to get things done was significantly greater than the other subcategories |
• Vigorous exercises reported a significantly shorter average time to fall asleep (14.7 min) compared with non-exercisers (26.1 min), light exercisers (22.4 min) and moderate exercisers (20.4 min) |
• The proportion of non-exercisers who report very bad sleep quality (14%) is significantly greater than vigorous exercisers (3%), moderate exercisers (4%) and light exercisers (4%) |
• The proportion of non-exercisers who report poor health (12%) is significantly larger than vigorous exercisers (1%), moderate exercisers (1%) and light exercisers (2%) [111] |
A meta-analysis of 66 studies found that acute exercise has small beneficial effects on total sleep time, sleep onset latency, sleep efficacy, stage 1 sleep and slow wave sleep. It also has a moderately beneficial effect on wake time after sleep onset. Regular exercise was found to have a moderately beneficial effect on sleep quality, small–medium beneficial effects on sleep onset latency, and a small beneficial effect on total sleep time and sleep efficiency. Effects were moderated by several factors including gender, age, baseline physical activity, exercise type, time of day, duration and adherence but were not moderated by exercise intensity or aerobic versus anaerobic subcategorisation [79].
Exercise and Sleep Apnoea
Sleep apnoea is a condition that can affect people who are overweight or obese, and people with cancer are often overweight/obese. A meta-analysis found that exercise has a beneficial effect in reducing the severity of sleep apnoea in patients with obstructive sleep apnoea. There were also significant improvements in cardiorespiratory fitness, daytime sleepiness and sleep efficiency [65].
Relaxation, Meditation and Yoga
Relaxation techniques can be useful when stress and worry causes sleep disruptions. In a recent study, mindfulness mediation had significant benefits for improving quality of sleep. A randomised controlled trial conducted over 6 weeks compared a mindfulness awareness practices (MAPs) intervention with sleep hygiene education (SHE) (both 2 h per week with assigned homework) in adults with moderate sleep disturbances. The MAPs group showed a significant improvement compared to the SHE group in relation to the Pittsburgh Sleep Quality Index and secondary health outcomes of insomnia symptoms, depression symptoms, fatigue severity and fatigue interference. There was no significant difference between groups for anxiety, stress or NF-κB concentration, although the study did find that concentration of NF-κB significantly declined in both groups [13].
Good sleep and meditation both have positive benefits for the optimal functioning of mind and body but there is a difference: in sleep the human mind–body is like a parked car with the engine on, whereas in meditation, the engine has been switched off.
The benefits of various forms of relaxation techniques have been discussed in Chap. 2 in relation to stress. Dealing with the underlying causes of stress where possible, as with cognitive behavioural therapy, is also advisable.
Cognitive Behavioural Therapy (CBT)
Cognitive behavioural therapy (CBT) is generally the first line therapy for insomnia treatment [96, 134] and research indicates that it can be more effective than sleeping medication for chronic insomnia [103].
Cognitive behavioural therapy for insomnia (CBT-I) is a structured programme, often comprising several techniques, that helps people with sleep disorders identify and replace beliefs, thoughts and behaviours that can contribute to poor sleep with habits that promote good sleep [96]. It helps people get rid of negative thoughts and worries that keep them awake and aims to replace sleep anxiety with positive thinking that links being in bed with sleeping [96, 112].
According to the Mayo Clinic, some of the CBT-I techniques include:
Sleep hygiene: changing lifestyle habits that influence sleep, e.g. not exercising regularly, smoking, drinking caffeine late in the day, etc., and learning to wind down an hour or two before going to bed.
Creating a good sleep environment: this can include keeping the bedroom quiet, cool and dark, eliminating distractions such as televisions and computers/tablets/laptops/cell phones in the bedroom, hiding the clock from view.
Stimulus control therapy: removes factors that condition your mind to resist sleep. Examples: the bedroom is only used to sleep and sex (and not reading emails or doing work); leaving the bedroom if you can’t fall asleep within 20 min and returning when sleepy.
Sleep restriction: involves reducing the time spent in bed, causing partial sleep deprivation and therefore making the person more tired the next night. Once sleep improves, time in bed is gradually increased.
Relaxation training: including meditation, muscle relaxation, imagery.
Remaining passively awake (paradoxical intention): involves avoiding any effort to fall asleep and letting go of the worry that you can’t sleep (since worrying that you can’t sleep can keep you awake).
Biofeedback: observing biological signs like heart rate, breathing and muscle tension then adjusting them (often uses a biofeedback device to record patterns and help identify those that affect sleep) [96].
CBT-I may also involve talking with a therapist either alone or in a group about thoughts and feelings about sleep, with the goal to settle the mind down [112]. Often several techniques are used together. Working with a therapist who can create an individualised treatment plan would be advisable. Again, the integrated model of care, where there is a team of professional healthcare providers is a most valuable one.
Research Evidence in Support of CBT for Insomnia
There is much research in support of CBT in the treatment of insomnia. For example, a randomised controlled trial (RCT) investigated the efficacy of five sessions of group CBT compared to ‘treatment as usual’ for insomnia delivered by mental health practitioners. The study found that the group CBT participants had significantly better sleep efficiency post-treatment than those who had usual care (though the difference was smaller between the groups at a 20-week follow-up), but there was no difference between the groups in terms of anxiety or depression symptoms [18]. This study was not specifically in cancer patients, however the results are still relevant and noteworthy.
A systematic review of five studies that investigated the efficacy of CBT in the treatment of insomnia found low to moderate grade evidence that CBT for insomnia is superior to benzodiazepines and non-benzodiazepine drugs in the long term and that its effects may be more durable than medications [103].
Other studies of CBT have been conducted in cancer survivors. For example, an RCT of CBT in breast cancer survivors found that those who received this therapy had significantly better sleep indices, lower levels of depression and anxiety, a lower frequency of medicated nights and a great quality of life compared with the control group (wait list), and that the therapeutic effects were maintained up to 12 months’ post-therapy [149]. Other studies in breast cancer survivors have also found significant benefits of CBT in treating sleep disorders [40, 130].
Sunshine and Bright Light Therapy
Where poor sleep is experienced by the patient with cancer, a suggestion can be to increase daytime exposure to the sun (which will also improve vitamin D levels) and reduce exposure to bright lights in the evening. This includes exposure to televisions, computer screens, smart phones and artificial light. This may help to ‘reboot’ the circadian rhythms and melatonin production in the body.
The use of computers, particularly at night, may lead to circadian disruption [154]. Computer use should be limited in the evening, and these, along with tablets, cell phones and laptops switched off a few hours before bedtime. They should also be left out of the bedroom, in particular in light of evidence that electromagnetic waves from mobile phones can affect the electrical activity of the brain [154], and the potential link between electromagnetic waves and cancer [44]. A study of children born in England and Wales found that compared with those who lived more than 600 m from a high voltage powerline at birth, children who lived within 200 m had a significantly higher risk of leukaemia [37]. Other studies have not found this association [123]. However, there is enough evidence beginning to form to sound a very large cautionary bell. This may well be the next health epidemic that currently no one wants to admit to, not unlike smoking in the twentieth century. In the meantime, why take chances? For patients with cancer, particularly brain cancer, it would be prudent to not hold cell phones against the head nor carry them on the body.
Supplements that Can Enhance Sleep
There are three key supplements that may be prescribed to enhance sleep. These are set out in Table 4.5.
Table 4.5
Supplements that may enhance sleep
Supplement | Note: dosages may vary with individuals |
|---|---|
Melatonin | Melatonin is a hormone made in the pineal gland in the brain, produced from the amino acid tryptophan Recommended dosage: 3 mg at night |
l-tryptophan | l-tryptophan is a precursor to melatonin that is necessary for the body to produce both melatonin and serotonin Recommended dosage: 1 gm at night |
Magnesium | Helpful if restless legs syndrome is adversely affecting sleep Recommended dosage: 360–600 mg at night |
Western Herbal Medicines
There are several western herbs that have beneficial actions where sleep is disturbed. Some of these are discussed in the next few pages.
Valerian and Hops
Extracts of the roots of valerian (Valeriana officinalis) and hops have both shown efficacy for the treatment of insomnia. Hops is well known as a bitter agent in the brewing industry and has a long history of use for sleep disorders. Valerian is proven to improve sleep quality without any other side effects. Taken together valerian and hops may be even more effective.
A systematic review of 16 randomised controlled trials examining 1093 patients found evidence that valerian improves sleep quality without producing adverse side effects. A dichotomous outcome of sleep quality—improved or not—was reported in six studies, and the pooled results indicated a significant benefit (Relative Risk of Improved Sleep was 1.8, meaning that those who took valerian were almost twice as likely to have improved sleep). However, like many systematic reviews, the review found evidence of publication bias and methodological problems in many of the studies. Despite this, the outcome of the review was favourable towards valerian’s use in insomnia [11]. Another meta-analysis of 18 RCTs concluded that valerian is effective in terms of subjective improvement of insomnia (sleep quality improvement) though its effectiveness has not been demonstrated with quantitative or objective measures [41].
Evidence suggests that the combination of valerian and hops may be more effective than placebo or valerian alone. An RCT of a fixed valerian hops extract combination (Ze 91019) was compared with a fixed single extract of valerian (similar amount as in the combination) and a placebo over four weeks in people suffering from non-organic insomnia. The study found that the combination extract (valerian plus hops) was significantly better than placebo whilst there was no significant difference between the single valerian extract and placebo in reducing sleep latency [74].
A very small study in children with intellectual deficits has also found that valerian over 8 weeks was associated with significant improvement in sleep (including increased total sleep time and improved sleep quality and reduced nocturnal wake time and reduced sleep latencies), in particular in children with deficits that involved hyperactivity [47].
Cautions
Since it has a sedative action, there are some cautions: in some people it may cause drowsiness, so caution should be taken if operating heavy machinery or driving a motor vehicle or any other activities requiring mental alertness within 2 h of consumption, and it should not be consumed with alcohol [59]. The usual precautions apply as for any form of herbal medicine—its potential for interactions with western medication should be checked.
St John’s Wort (Hypericum perforatum)
St John’s Wort has a long history of assisting patients with depression, and may be useful to assist those patients with sleep problems who also suffer from depression. As stated previously in this chapter, insomnia is associated with anxiety and depression [8, 166]. There is limited data on the efficacy of St John’s Wort in the treatment of insomnia that is not related to depression [101].
A systematic review of 29 studies in 5489 patients with depression that compared extracts of St John’s Wort to placebo or standard antidepressants over 4–12 weeks concluded that the St John’s Wort extract was superior to placebo, similar in efficacy to antidepressants and had fewer side effects than standard antidepressants [90].
St John’s Wort has been found to significantly increase the latency to rapid eye movement (REM) sleep without any other effects of sleep architecture [155].
Chamomile
Chamomile has a sedative action and has a history of use in the treatment of insomnia. German chamomile (Matricaria recutita) is widely used as a herbal product for sleep, and preclinical studies indicate that the flavonoid constituent apigenin produces sedative effects via its ability to modulate y-aminobutryic acid (GABA) receptors [175, 189, 191].
There has not been a lot of research into the effects of chamomile specifically on insomnia. One study found that 12 weeks of a herbal extract containing chamomile and Angelica sinensis for hot flushes alleviated sleep disturbances as well as fatigue [82]. Another study did not find that chamomile was efficacious in primary insomnia—they found modest but non-significant improvements in sleep latency, night-time awakenings and daytime functioning compared with placebo and no differences in subjective sleep efficiency and total sleep time [191]. A more recent study investigating the effect of drinking chamomile tea for two weeks in postnatal Taiwanese women found that compared with the control group (regular postnatal care), those drinking chamomile tea had significant improvements in physical-symptoms-related sleep inefficiency and symptoms of depression. The positive effects were immediate rather than long term—when the two groups were compared 4 weeks after cessation of the study, there was no significant difference between the two groups [22].
There is research that indicates the usefulness of chamomile in the treatment of anxiety, and given the links between anxiety and sleep problems, chamomile may be useful as an adjunct treatment in anxious patients with sleep problems. An RCT in people with mild-moderate generalised anxiety disorder found that chamomile extract significantly reduced anxiety in comparison to placebo [4]. Another study found that chamomile oil was associated with increased comfortable feelings and decreased alpha 1 (8–10 Hz) recordings of the EEG in the parietal and temporal regions of the brain [95]. These studies therefore support its use in stress reduction.
Kava
Kava (Piper methysticum) is a psychotropic plant from South America that has anxiolytic ability. It is able to modulate GABA activity via alteration of lipid membrane structure and sodium channel function, and can inhibit monoamine oxidase B and inhibit noradrenaline and dopamine reuptake [145]. A systematic review found that the weight of evidence indicates that kava is efficacious in treating anxiety, with significant results in four out of six studies. The review also made several recommendations around safety. These included advising the use of the traditional, water soluble extracts of the root, and avoidance of concurrent alcohol use, avoidance of high doses if driving or operating heavy machinery, and caution with other psychotropic medication. They also advised routine liver function tests for those who used it on a regular basis [145].
In a single-arm study (no control), kava and valerian separately were both found to be effective in reducing severity of stress and stress-induced insomnia [179]. The most common side effects were vivid dreams for valerian (16%) and dizziness for kava (12%) [179]. When this study was extended to assess the efficacy of the combination of valerian and kava, the combination was found to be more efficacious than the single products in reducing insomnia [180]. In this second study, 67% reported no side effects on kava, 53% reported none on valerian and 53% reported none on the combination. The commonest side effects were vivid dreams (for the combination (21%) and valerian alone (16%) and gastric discomfort and dizziness for kava (3%) [180].
Passionflower (Passiflora)
Passionflower (Passiflora) is also used to treat problems like anxiety. A systematic review was conducted, however only two studies met the inclusion criteria, a total of 198 participants when pooled. One study indicated that passiflora was as effective as benzodiazepines in alleviating anxiety. The reviewers were unable to draw any conclusions on efficacy or safety due to the small number of studies [104]. Another systematic review of complementary therapies for the treatment of anxiety concluded that there was strong evidence that supplements containing extracts of passionflower were efficacious in treating anxiety symptoms and disorders [83].
Ashwagandha (Withania somnifera)
The root of the Indian herb Ashwagandha is used in Ayurveda, Indian traditional medicine, and has adaptogenic benefits, helping the body cope with internal stresses such as anxiety and insomnia and external stresses such as toxins [147]. The major biochemical constituents are steroidal alkaloids and steroidal lactones in a class of constituents called withanolides [172].
A review of the literature indicated that Ashwagandha is able to reduce stress and has anti-inflammatory, antitumor, antioxidant, immunomodulatory, haemopoetic, and rejuvenating properties, and exerts a positive effect on the endocrine, cardiopulmonary, and central nervous systems, although the mechanisms of action are not fully understood [102]. It has also been found to have radiosensitising effects as well as antitumor effects in experimental tumors in vivo [34]. Toxicity studies indicate that Ashwagandha appears to be safe [102].
Animal research and clinical trials support the therapeutic use of this herb for anxiety as well as cognitive and neurological disorders, including Parkinson’s disease, and inflammation [172]. It is an adaptogen that can be used for patients with insomnia, nervous exhaustion and debility due to stress. It is also an immune stimulant that can be useful in patients with low white blood cells [172].
Animal research has demonstrated anxiolytic and antidepressive effects of Ashwagandha that are comparable to the benzodiazepine lorazepam (for anxiolytic activity) and imipramine (anti-depressant) [172].
A systematic review that included five studies concluded that Ashwagandha was more effective than placebo at alleviating anxiety and stress and that in four out of the five, the results were statistically significant (one study missed out on claiming statistical significance because the p-value was equal to 0.05, right on the cut-off in other words). The reviewers cautioned that there was a high risk of bias in the studies and that because of the heterogeneity of the studies, they were unable to pool the results in a meta-analysis [128].
Lemon Balm (Melissa officinalis)
Lemon balm has been traditionally used to aid sleep in the case of restlessness or insomnia due to mental stress [59]. Several studies have found that the combination of valerian and lemon balm to be particularly effective. For example, this combination was found to significantly reduce levels of sleep disorders in menopausal women compared with placebo [165]. Another RCT in healthy volunteers found that the combination of valerian/lemon balm was associated with a significantly higher quality of sleep compared with the placebo group, and that is was well tolerated and safe (no serious adverse events were reported, and there was no significant difference in terms of proportion of adverse events in the valerian/lemon balm group compared with the placebo group) [21]. In children under 12 years of age suffering from restlessness and dyskoimesis, in an open, multicentre study, a combination of valerian and lemon balm was found to reduce symptoms markedly (restlessness improved in 70% and dyssomnia improved in 81%), and no adverse events were associated with the medication [109].
Caution is recommended if operating heavy machinery or driving a motor vehicle or doing any activity that requires mental alertness, as this herb may cause drowsiness in some people. In addition, the consumption of alcohol or concurrent use of other health products or medications that have sedative actions is not recommended [59].
Essential Oils
In folklore, people used to put lavender in their pillows to promote sleep when they were restless. There is evidence that aromatherapy with lavender oil may slow the nervous system activity and promote relaxation and sleep. Massage with lavender essential oil may also reduce anxiety, and promote better sleep [168]. In Germany, lavender flowers are approved as a tea for insomnia, nervous stomach irritations and restlessness [168].
Burning lavender essential oil in an oil burner can promote relaxation. The electric oil burners with timers that switch off automatically may be safer than those with candles in case the patient falls asleep.
Homoeopathy
There is some evidence that homoeopathy treatments can assist with insomnia (as well as other symptoms associated with cancer). The following homoeopathic remedies may be useful for particular patients, depending on the nature of their presentation: Coffea Cruda, Nux Vomica, Cocculus, Aconite, Chamomilla, Arnica, Belladonna, Gelsemium, Capsicum, and Staphysagria [113].
A systematic review of four randomised controlled trials that compared homoeopathic medicines to placebos in the treatment of insomnia did not find evidence of a significant difference between treatment and control groups, though two showed a trend favouring homoeopathic medicines. These studies were judged to be of poor methodological quality and probably ‘underpowered’ (this generally means that they would not have had sufficient numbers of participants to be able to detect a change in the outcome variables they were testing). In addition, one cohort study reported significant improvements compared with baseline, and there were no RCTs that tested out individualisation of homoeopathic treatment [27].
Since that review was published, a higher quality double-blind RCT has been conducted investigating the efficacy of homoeopathic simillimum treatment compared with placebo in the treatment of chronic insomnia. The study found that the homoeopathic treatment resulted in a significant increase in sleep duration compared with placebo. Sleep quality was significantly improved in the homoeopathic group at the end of the study compared to baseline, and compared with placebo [113].
It is important that an experienced homoeopath assesses and prescribes homoeopathic treatments.
Chinese Medicine and Insomnia
Chinese medicine is underpinned by its own philosophies and theories, with its own medical language, and has been practised for over 3000 thousand years. Unlike biomedicine, insomnia is seen as a condition not of the brain or mind, but of the Heart, capitalised to distinguish it from the usual biomedical understanding. The Chinese medical concept of an organ system extends well beyond the anatomical and physiological functioning as we know it in western medicine. For example, each organ system has a particular emotion associated it with, and a sense organ, connected to it via the meridian system. The meridian system is a system of channels throughout the body, within which Qi, a kind of energetic life force, circulates. The Heart, in Chinese medicine, is seen as the ‘seat of consciousness’ or where the ‘mind’ is housed [117].
Where the ‘Mind’ Is Located
In western medicine, of course, we understand the brain to be where ‘mind’ is located. However scientific research is turning this fixed idea somewhat on its head (pardon the pun, it’s intended). One only has to read cardiologist Paul Pearsall’s book ‘The Heart’s Code’ [122] and read about memories transferred from heart transplant donors to the recipients to start to wonder whether the ancient Chinese weren’t onto something after all. The field of ‘neurocardiology’ envisages the heart as a sensory organ that can process and encode information and that functions in concert with the brain but also independently of it [98]. The heart and the gut have their own neural networks. Research has established that in addition to affecting autonomic regulatory centres, cardiac afferent neurological input can also affect higher brain centres involved in emotional processing and perception. Changes in both afferent and efferent autonomic activity have been found to be associated with changes in heart rhythm patterns with positive and negative emotions associated with increased and decreased coherence of heart rhythm respectively [98]. Research has also shown that the heart and brain can receive and process information about future events before the event occurred, and that the heart receives such ‘intuitive’ information before the brain and sends a different pattern of afferent signals to the brain which modulates the frontal cortex [99].
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