Sleep: Why It’s Important and How to Get Enough
“I’ve been diagnosed with chronic fatigue syndrome, and it seems accurate because I have fatigue, chronic pain, and brain fog. So how in the world can it be that I’m exhausted throughout the day, but I lie awake practically every night? I just don’t understand this, and it’s making me crazy. Is insomnia normal in a person with my problem? And is it even treatable? Does anyone else with chronic fatigue ever have this problem—and if they do, what can they do about it?” asked a very frustrated Miranda.
Sleep is crucially important to everyone’s good health, but getting a good night’s sleep is a common problem experienced by many people with CFS. This chapter explores chronic insomnia, sleep apnea, and restless legs syndrome (RLS) and offers ideas on how to address these key sleep issues. Most research studies have shown that when chronic insomnia is treated, other problems areas such as pain and fatigue also improve.1
Sleep is a concern for many adults; the CDC reports that more than a third of Americans (35%) don’t get enough sleep.2 Sleep problems are amplified among people with CFS when compared to other chronic neurological illness. Researchers compared sleep quality in patients with CFS and multiple sclerosis (MS) and found that 55 percent of the subjects with CFS reported severe, unrefreshed sleep. Among the patients with MS, 28 percent reported having this problem.3
In this chapter, I outline the common sleep disorders and the respective treatment that people with CFS confront. Nonpharmacological solutions such as improving sleep hygiene and incorporating stress-reducing techniques, such as progressive muscle relaxation, are explored. Many people are drawn to over-the-counter herbs and supplements such as chamomile or melatonin, and I describe the potential utility for these herbs and supplements. A word of caution: even though these drugs are “natural,” they have some concerning side effects that should be understood.
Sometimes these approaches are not sufficient, and more decisive measures need to be taken. I describe prescription sleep medications and provide a discussion about what role each drug may play for patients with CFS.
The sleep disturbances so common to patients with CFS is rarely an isolated symptom; typically, other symptoms coexist and complicate the clinical presentation. For those who have chronic pain associated with insomnia, refer to the narrative and case studies in Chapter 8. In addition, many people with CFS suffer from problems with depression and anxiety, issues that are addressed in Chapter 4. This chapter also addresses medical conditions that may accompany or need to be distinguished from CFS.
Considering Insomnia
Insomnia has many component parts. The most common definition is the inability to sleep, usually a problem for people who need to sleep at night. But there are other aspects of insomnia, such as having trouble falling asleep, frequent awakenings, having trouble getting back to sleep once you have woken up, and feeling unrefreshed from sleep when you eventually do wake up—no matter how many hours you have slept. Insufficient or nonrestorative sleep at night may lead to excessive daytime sleepiness. Insomnia is linked to numerous problems, such as trouble concentrating, memory problems, and an overall reduced quality of life.4
In general, women are more likely to suffer from insomnia than men, and not everyone shares the same risk for developing the sleep disturbance. Specific insomnia risks include having an irregular work schedule (midnight nurses have high rates of sleep disruption) or having sleep apnea or fibromyalgia. Individuals experiencing high levels of psychological stress, recurrent depression, or other mental health problems are also at risk.5
Most people with CFS complain about daytime fatigue and the general assumption, advanced by research included later in the next section, is that improved nighttime sleep remedies daytime fatigue. That is not always true. Nighttime sleep integrity is essential, but it does not ensure a sense of well-being in the daytime. In other words, for many individuals with CFS, treatment with morning medications, specifically long-acting stimulants, remains necessary even in the presence of ideal nighttime sleep. For a fuller discussion of treatment for daytime fatigue, refer to Chapters 5 and 6.
Resolving Your Insomnia May Decrease Daytime Fatigue
Programs that address psychosocial and insomnia difficulties of CFS patients reveal that participants reported less daytime fatigue. Norwegian researchers assembled 122 subjects with chronic fatigue syndrome and provided a 3.5-week comprehensive course of rehabilitation and return-to-work therapy. The researchers found that by addressing their insomnia, the subjects enjoyed a significant improvement in their fatigue as well as in their ability to recover from stressful situations. The researchers concluded, “Insomnia severity may be a maintaining factor in chronic fatigue and specifically targeting this in treatment could increase treatment response.”1
Note
1.Havard Kallestad, et al., “The Role of Insomnia in the Treatment of Chronic Fatigue,” Journal of Psychosomatic Research 78 (2015): 1.
Do You Have Good Sleep Hygiene?
People practice good hygiene in other daily routines, such as washing their hands before preparing food, brushing their teeth after meals (or at least once a day), and taking showers. Here are some of the basics of good sleep hygiene that can significantly improve the life of a person with insomnia:
•Use your bedroom for sleep and sex only
•Go to bed at the same time every night
•Stop worrying about not sleeping
•Avoid clock watching
•Avoid caffeine (chocolate, coffee, or tea) after dinner
•Could it be your medication?
•No alcohol before bed
•No big meals before bedtime
Use Your Bedroom for Sleep and Sex Only
People struggling with insomnia should limit the scope of their bedroom’s function. Some people decide bedtime is a great time to read e-mails, send texts, or rage on Twitter. Very bad idea! All these activities and even something as noninteractive as reading are stimulating and are known to hinder active sleep.
Nor is your bedroom a good place to perform your daily exercises—keep that health living activity in the gym. Instead, limit your bedroom to two functions: sleep and sex. If you get into the mind-set that these two activities are the purpose of your bedroom, then you are less likely to fall into the unconscious habit of thinking that you need your television, tablet, or other devices to entertain you. One more thing: no snacking in your bedroom at any time.
Go to Bed at the Same Time Every Night
The brain craves repetition, and one essential routine for good sleep is to go to sleep at the same time every night. More importantly, it is important to wake up at approximately the same time every morning. You may deserve to stay up later weekends and holidays; unlimited sleeping in is a core pleasure for many people. That might be acceptable choice for a person who does not have insomnia problem, but for those who do have insomnia, waking up at noon on Saturday and Sunday will make the 7:00 a.m. alarm on Monday morning very disruptive.
Stop Worrying about Not Sleeping
Most of us have found ourselves awake at midnight or 1:00 a.m., when we know that we must wake up at 7:00 a.m. to get ready for work. So what do we do? We worry that we only have six more hours to sleep. So hurry up brain. Get to sleep. Then it’s 2:00 a.m. and 3:00 a.m., and as the clock ticks, it is easy to get panic-stricken about the limited amount of time that’s left. Does this type of thinking help a person relax into Dreamland? It does not! Excessive worry has the opposite effect. Have faith that your body will regulate itself and will adjust to occasional exposure to short sleep nights.
Avoid Clock Watching
You may need an alarm clock to wake you up in time in the morning, but that does not mean the face of the clock needs to be visible to you. Simply get up, shut the alarm off, and start your day. Clock watching is like panicking as the time passes, but it requires a clock. Turn it around so you cannot see it. It will still go off at the right time in the morning. If you normally wear a watch in the daytime, take it off at night and put it face down and out of reach.
Generally, Stay Away from Caffeine after Dinner
Caffeine is a stimulant, which is why substances containing caffeine should be avoided after the later afternoon. Coffee, tea, coffee, and many carbonated soft drinks have high caffeine content and are associated with excitation of the nervous system. Every once in a while, however, the opposite is true. I have a few patients who report that caffeine allows them to relax and focus on falling asleep. So while staying stimulant free is generally advised, there are exceptions to the rule.
Avoid Daytime Naps
You may think naps must be healthy, because don’t people in other countries take regular siestas? That may be part of their culture, but unless it is also part of yours, afternoon naps—or any naps—are a bad idea. Naps will train your body to need fewer hours of nighttime sleep. In addition, regular naps will worsen insomnia. In well-run nursing homes, the elderly are purposely kept busy during the day to discourage napping and to promote nighttime sleep patterns.
Could the Problem with Insomnia Be Related to Your Medications?
Some medications, including some over-the-counter medicines, may cause delay sleep onset. Certain over-the-counter cold and flu medications can prevent or delay sleep because they contain caffeine or phenylephrine. Pseudoephedrine, a more potent decongestant, is more highly regulated in select states and dramatically impairs sleep. Other medications may have an activating effect, including the stimulants that I discus extensively in other chapters for counteracting the effects of chronic fatigue. There are times when stimulant medication needs to be given in the afternoon (generally to augment waning doses given in the morning), but the effects on sleep need to carefully considered before afternoon dosing is undertaken. Other commonly used medications that may cause insomnia include beta-blockers, clonidine, and antidepressants that block the reuptake of serotonin such as fluoxetine (Prozac).
A few shots of alcohol before bedtime has been suggested, but this is not a sustainable practice over time. What usually happens is the person falls asleep (or passes out) in the evening and then wake up hours later, dehydrated and with throbbing head pain. The effect on next day functioning are not good. Binge drinking is not a desirable way to restore basic sleep needs, but a glass of wine may be helpful on occasion.
No Big Meals before Bedtime
It may be Parisian to eat a sumptuously large meal at 8:00 p.m. or 9:00 p.m. or later, but when you plan to go to bed at 11:00 p.m., the heavy load of food may make proper digestion pretty challenging. In many households, the “big meal of the day” is the evening meal, but it might be prudent to consume dense calories earlier in the day. Certainly, a large noon meal may also cause a person to get sleepy. Think how soporific the midday Thanksgiving meal is, when many people gorge themselves, and afterward, all they want to do is lie down and sleep.
Herbal or Supplemental Remedies
Sometimes people with sleep problems don’t want to take prescribed medications, but they know they need extra help to overcome their insomnia. In such cases, sleep problems may be improved by taking melatonin or herbal remedies like chamomile, valerian, kava, or passionflower. (Some of these come in the form of teas.) Keep in mind that all drugs come with both benefits and side effects, and alternative remedies derived from natural plants are no exception to this rule; for example, cobra venom and opium are natural substances, but it’s best to stay clear of them. See Table 10.1 for a listing of possible supplements that may help you obtain the sleep you need.
Some herbs and supplements interact with other medications, which means that they may increase, decrease, or completely counteract the effects of other drugs that you may take. For example, in the past, sometimes St. John’s Wort was used for depression and for insomnia; however, this herb causes so many dangerous interactions with multiple drugs that it generally should be avoided. For example, it can stop birth control pills from working, increase the effect of a blood thinner, and reverse the effects of chemotherapy drugs taken by cancer patients—and these are only a few of the potentially problematic effects.
Table 10.1 Considering the Pros and Cons of Herbal/Supplemental Sleep Remedies
Name |
Herb or Supplement? |
Possible Side Effects and Warnings |
Chamomile |
Herb |
Patients may be allergic to it, especially people allergic to ragweed, chrysanthemums, daisies, or marigolds; should not be used by people taking the blood thinner warfarin or cyclosporine, a drug used to prevent organ transplant rejections. |
Melatonin |
Supplement |
May cause headaches, nausea, and dizziness. |
Valerian |
Herb |
May cause headache, dizziness, digestive disturbances, and itching. |
Kava |
Herb |
May harm the liver |
Passionflower |
Herb |
Should not be used during pregnancy because it may induce contractions. |
St. John’s Wort |
Herb |
Interacts with many drugs, such as MAOI antidepressants, birth control pills, warfarin, some cancer medications. Side effects may include dry mouth, dizziness, headache, anxiety, sexual dysfunction. |
Sources: National Center for Complementary and Integrative Health, “Chamomile,” September 2016, https://nccih.nih.gov/health/chamomile/ataglance.htm (accessed June 10, 2019); Darren J. Hein, “OTC Insomnia Supplements: The Latest Evidence” March 15, 2019, https://www.medscape.com/viewarticle/910144_3 (accessed June 10, 2019); National Center for Complementary and Integrative Health, “Valerian,” September 2016, https://www.medscape.com/viewarticle/910144_3 (accessed June 12, 2019); National Center for Complementary and Integrative Health, “Melatonin: In Depth,” May 2015, https://nccih.nih.gov/health/melatonin (accessed June 10, 2019); National Center for Complementary and Integrative Health, “Passionflower,” September 2016, https://nccih.nih.gov/health/passionflower (accessed June 10, 2019).
Be sure to tell your physician before trying any herbs or supplements to help with resolving a problem with insomnia. Bear in mind that many health care providers are not familiar with the intricacies of supplements for several reasons. First, the FDA does not consider these supplements medications, so they are not subjected to the same rigorous scientific testing as prescribed medications. Usually there is no existing data exploring long-term safety, and the impact the supplement has on other medications is unknown. Second, the quality control of food additives is not consistent. Some agents are imported from nations with lower drug purity standards. With supplements, the old mantra “Let the buyer beware” applies.
Sleep Medications for Chronic Insomnia
Sometimes prescribed sleep medications are needed to obtain sufficient sleep. Many people are apprehensive about taking sleep medications to treat their chronic insomnia, as they may be fearful of becoming dependent or have concerns that they might oversleep the next morning. In reality these medications are quite safe, assuming the user follows the physician’s recommendations. Avoid alcohol and other drugs, especially opioids, when taking these sedative hypnotics.
Considering Specific Sleep Medications
The medications used most often for sleep are related to the benzodiazepine class. Some of the older antidepressants are also for sleep induction, albeit at lower doses than are used to elevate mood. Table 10.2 covers the most commonly prescribed sleep medications and discusses what type of medication each is, its key benefits, and common side effects that may occur with their use.
The benzodiazepine receptor agonist (BzRA) is a common category of sleep medications, and it includes such drugs as zaleplon (Sonata), Eszopiclone (Lunesta), and zolpidem (Ambien). These drugs are specifically approved by the FDA for treating insomnia, and their pharmacological effects are more directed on sleep than benzodiazepines like alprazolam (Xanax) and diazepam (Valium). Melatonin is a readily available sleep remedy that engages natural melatonin receptors in the body to induce sedation and sleep. The melatonin receptor agonist drug ramelteon (Rozerem) also exploits the melatonin pathways. The orexin receptor antagonist suvorexant (Belsomra) is a newer category of sleep medication; it reverses the natural wakefulness of the orexin/hypocretin system in the body.6
An older but often overlooked antidepressant, doxepin (Silenor), is specifically approved by the FDA as a treatment for chronic insomnia. Trazadone (Desyrel) is also an antidepressant, and though it never received official FDA clearance, it is frequently used off-label as a sleep-inducing medication.
Table 10.2 FDA-Approved Sleep Medications
Brand (Generic) Name |
Type of Medication |
Possible Side Effects |
Zolpidem (Ambien, Ambien CR, Edluar, Intermezzo, and Zolpimist) |
Benzodiazepine receptor agonist, also known as a non-benzodiazepine hypnotic |
Headaches, sleepiness, falls |
Esziopiclone (Lunesta) |
Benzodiazepine receptor agonist |
Metallic taste in the mouth, dizziness, headache, sleepiness |
Zaleplon (Sonata) |
Benzodiazepine receptor agonist |
Drowsiness, headache, nausea, may worsen symptoms of depression in people with depressive disorders |
Ramelton (Rozerem) |
Melatonin Receptor Agonist |
Sleepiness, dizziness, and fatigue |
Suvorexant (Belsomra) |
Orexin receptor agonist |
Not recommended for patients with narcolepsy |
Doxepin (Silenor) |
Antidepressant |
Drowsiness, dizziness, difficulty with urination, constipation, nausea and vomiting |
Sources: Pradeep C. Ballu and Kaur, Harleen, “Sleep Medicine: Insomnia and Sleep,” Missouri Medicine 116, n. 1 (January/February 2019): 68–75; John M. Eisenberg Center for Clinical Decisions and Communications Science, “Managing Insomnia Disorder: A Review of the Research for Adults,” August 2017, https://www.ncbi.nlm.nih.gov/books/NBK537838/ (accessed June 12, 2019).
What about Marijuana and CBD?
Marijuana and CBD oil were covered in depth in Chapter 8, where possible remedies for chronic pain are discussed. Assuming such substances are legal in their state, some readers find that these remedies may alleviate their insomnia. The chapter also addresses concerns about marijuana and CBD oil. Refer to that chapter, and take these issues into account before deciding on cannabis.
Considering Cognitive Behavioral Therapy for Insomnia (CBT-I)
Researchers have shown that CBT for insomnia is highly effective and usually resolves insomnia symptoms in 8–10 sessions or fewer. A CBT therapist collects a thorough history of the patient’s insomnia problem and then makes individualized suggestions. Sometimes the suggestions revolve around improving sleep hygiene through science-based psychoeducation that busts common myths and misconceptions about sleep, such as “I must get at least eight hours of sleep to function.” Participants in CBT-I find relief in learning that 100 percent of deep sleep occurs within 5.5 hours of sleep, and studies show that daytime performance is adequately maintained. Research also indicates that six–seven hours of sleep is associated with the longest life expectancy.
The therapist identifies mistakes that are commonly made, such as lying in bed at night, thinking about all your most challenging problems, or what you should have said when the boss or another person made a nasty comment to you that really rankles. Repetitive negative thoughts that occur before bed, during nighttime waking, and in the morning are captured by the patient and then replaced by helpful and true facts about sleep. Patients are given tools to track their sleep habits using a weekly time log and instructed how to calculate their sleep efficiency, which is the total amount of sleep divided by total time spent in bed. The cognitive behavioral therapist will help determine your key sleep issues and individualize the therapy to help you resolve your insomnia.
A CBT therapist usually can resolve insomnia problem in 8–10 sessions or fewer. The therapist will ask many questions about the patient’s insomnia problem and then make individualized suggestions. Sometimes the suggestions revolve around improving sleep hygiene, but the therapist can also identify other mistakes that are commonly made, such as lying in bed at night ruminating about the day’s events. The cognitive behavioral therapist will help determine your key sleep issues and individualize the therapy to help you resolve your insomnia issues.
In a study reported in 2018 in Korea, the researchers provided CBT-I to 41 subjects with insomnia, most of whom also received sleep medications. The control group of 100 subjects received pharmacotherapy (sleep medications) only. At the conclusion of the study, the researchers found that the CBT-I reduced the need for sleep medications in the study group significantly compared to the control group, and the case closure rate was higher—meaning those subjects no longer needed therapy.7
Other Therapies That Improve Chronic Insomnia Problems: Progressive Muscle Relaxation
Progressive muscle relaxation is another approach that may help you get yourself to sleep and overcome your problems with chronic insomnia, particularly when you are feeling anxious. Progressive muscle relaxation basically involves mentally tightening and then loosening muscles in your body, starting with your toes and slowly moving up to your head and neck. This form of relaxation therapy helps to alleviate tension and stress as you concentrate on the parts of your body and helping each group of muscles tense and then relax, in a graduated, stepwise fashion.
I’ve adapted the step-by-step instructions provided by the Veterans Administration to military veterans who are battling insomnia.8 The exercise takes about 10 minutes to complete and hopefully sleep will greet you before the exercise is complete. If not, start again and allow your body to transition to peaceful sleep.
1.Find a quiet place to sit or lie down.
2.Close your eyes if you can. If this makes you uncomfortable, you can keep your eyes open during this exercise.
3.Take very slow, deep breaths by inhaling through your nose with your mouth closed. Do this to a count of four.
4.Repeat this breathing exercise four times. But if you start to feel dizzy, go back to your normal breathing pattern.
5.Start at your feet, and as you inhale, tighten these muscles and hold the tension briefly. Then, as you breathe out, let all the tension flow out, as if it were coming out with your exhaled breath. Feel the difference between the tension phase and the relaxation phase.
6.Press the balls of the feet into the floor and raise your heels, allowing the calf muscles to contract. Feel this tension in the calves. Then release, and observe the muscles relaxing. Have the tension and relaxation match your breath. Then tighten the knees and allow your legs to straighten. Feel the lightness in the front of the legs and notice the tension while inhaling a breath. Then release on the exhale, allowing the legs to bend and relax back onto the floor.
7.Continue this tightening and relaxing process as you move up through the body. Move to the stomach and then to the hands and arms.
8.Finish the exercise by tensing the muscles in the face, tightening the face, and then letting all the tension flow out with the exhaling breath.
9.Notice if you feel any areas of tension that remain in the body and work on tightening and relaxing those areas.
10.At the end of the exercise, relax. And hopefully, you may fall fast asleep.
Considering Yoga, Meditation, or Tai Chi
In addition to the recommendations already made in this chapter, many readers may benefit from taking classes in yoga, meditation, or tai chi. These Eastern practices have been employed for millennia to enhance relaxation and promote healthy living. As with progressive muscle relaxation, these practices encourage mind-body integration. Many cities offer these programs in private studios, local gyms, or community centers.
Considering Sleep Apnea
Sleep apnea is characterized by short periods of breathing cessation during sleep. Individuals with this medical condition stop breathing for short periods during sleep. The condition may be suspected because of loud snoring (usually reported by a spouse or partner) and reported apneic periods of gasping and choking during sleep. The frequency and severity of the apnea events is assessed during a formal sleep study conducted in a sleep laboratory. Sleep apnea is most accurately diagnosed by a sleep specialist who can provide specialized treatment.
The most common type of OSA condition is caused by excessive soft tissue in the back of the throat that blocks the passage of air.9 When this obstruction result in frequent apneas, deep and restorative sleep is nearly impossible to achieve. Impaired nighttime sleep results in excessive daytime sleepiness, and OSA patients may also suffer from headaches, irritability, difficulty concentrating, anxiety, and depression. According to the American Sleep Apnea Association, an estimated 22 million Americans experience sleep apnea, and many of them have gone undiagnosed despite having long-standing sleep disturbances. No one primary complaint characterizes the patient with OSA. Some report sleeping too much, but many others say that they have a problem falling asleep at the beginning of the night.10
Sleep apnea is helped by using pillows and other devices that keep patients from sleeping on their backs. Certain oral appliances that keep the airway open during sleep may be helpful. If these measures don’t work, the person may receive a CPAP device that delivers humidified room air through a mask during sleep. Although some OSA patients object to wearing a device during sleep, improvements in mask design have allowed patients to better tolerate the device.11
Restless Legs Syndrome (RLS)
Restless legs syndrome (RLS) is a disorder that sounds like its name: the sufferer has a compelling sensation to move about when lying down. The sensations of RLS can feel like an aching or a creeping feeling, and although it is primarily experienced in the legs, it may also occur in the arms or even the head or chest. These sensations may range from annoying all the way up to painful and most often start in the lower extremities but can be felt throughout the body. Restlessness becomes most apparent at night when there is quiet and few distractions. Often there is little available to palliate the symptoms; the patient will resort to calisthenics or hot showers to decrease the discomfort. Usually the restlessness returns quickly and there is no time to transition into sleep. RLS causes daytime sleepiness and extreme fatigue, making it difficult to perform many daytime tasks. RLS symptoms have often been reported in individuals who suffer from ADHD. The National Institute of Neurological Disorders and Stroke estimates that RLS can decrease work productivity by as much as 20 percent.12
RLS appears to be an inherited disorder affecting up to 10 percent of American population divided equally between men and women13 and can be related to iron deficiency and the consumption of caffeine, alcohol, or nicotine. RLS can emerge during pregnancy and self-resolve after birth.
Treatment for RLS includes avoiding exacerbating substances, such as caffeinated foods and beverages, alcohol, and tobacco. People low in iron should receive iron supplementation, and a deficiency is easily detected in a blood test.
Antiseizure drugs are usually the medications of choice to treat RLS, particularly gabapentin enacarbil (Horizant), which is specifically indicated for treatment of RLS. Gabapentin (Neurontin) or pregabalin (Lyrica) may also be used, and in certain cases, dopamine agonists such as ropinorole (Requip) and pramipexole (Mirapex) are prescribed. Benzodiazepines may also be prescribed, including clonazepam (Klonopin) or lorazepam (Ativan). Benzodiazepines are sedating and allow the individual to experience restful sleep; however, this class of medication should be used with considerable care, as it is habit-forming. Never take more than the prescribed dosage ordered by the physician.
Chronic insomnia is a complicating factor in the lives of many patients with CFS. There are many causes of insomnia and many treatment responses, ranging from changes in behavior to the use of medications or physical devices. To the persistent individual who seeks answers, explanations and solutions are available.
Notes
1.Havard Kallestad, et al., “The Role of Insomnia in the Treatment of Chronic Fatigue,” Journal of Psychosomatic Research 78 (2015): 427–432.
2.Centers for Disease Control and Prevention, “1 in 3 Adults Don’t Get Enough Sleep,” February 16, 2016, https://www.cdc.gov/media/releases/2016/p0215-enough-sleep.html (accessed June 16, 2019).
3.Vageesh Jain, et al., “Prevalence of and Risk Factors for Severe Cognitive and Sleep Symptoms in ME/CFS and MS,” BMC Neurology 17 (2017), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5477754/pdf/12883_2017_Article_896.pdf (accessed June 10, 2019).
4.Jasvinder Chandra, “Insomnia,” Medscape, September 11, 2018, https://emedicine.medscape.com/article/1187829 (accessed June 12, 2019).
5.Office of Women’s Health, “Insomnia,” November 30, 2017, https://www.womenshealth.gov/a-z-topics/insomnia (accessed June 10, 2019).
6.Pradeep C. Ballu and Kaur, Harleen, “Sleep Medicine: Insomnia and Sleep,” Missouri Medicine 116, n. 1 (January/February 2019): 68–75.
7.Kyung Mee Park, et al., “Cognitive Behavioral Therapy for Insomnia Reduces Hypnotic Prescriptions,” Psychiatry Investigation (2017), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5976005/pdf/pi-2017-11-20.pdf (accessed June 10, 2019).
8.Veterans Administration Employment Toolkit, “Relaxation Exercise: Progressive Muscle Relaxation,” n.d., https://www.va.gov/vetsinworkplace/docs/em_eap_exercise_PMR.asp (accessed June 10, 2019).
9.American Sleep Apnea Association, “A Very Short Course on Sleep Apnea,” n.d., https://www.sleepapnea.org/learn/sleep-apnea-information-clinicians/ (accessed June 12, 2019).
10.Jasvinder Chandra, “Insomnia,” Medscape, September 11, 2018, https://emedicine.medscape.com/article/1187829 (accessed June 12, 2019).
11.National Institute of Neurological Disorders and Stroke, “Restless Legs Syndrome Fact Sheet,” May 2017, https://www.ninds.nih.gov/disorders/patient-caregiver-education/fact-sheets/restless-legs-syndrome-fact-sheet (accessed June 16, 2019).
12.Ibid.
13.National Institute of Neurological Disorders and Stroke, “Restless Legs Syndrome Fact Sheet,” May 2017, https://www.ninds.nih.gov/disorders/patient-caregiver-education/fact-sheets/restless-legs-syndrome-fact-sheet (accessed June 16, 2019).