Patrick McKeown

• Insomnia is a sleep disorder characterized by difficulty sleeping¹. You may find it hard to fall asleep or struggle to stay asleep for as long as you want
• Common features of insomnia include daytime sleepiness, irritability and poor concentration
• Insomnia increases your risk of road traffic accidents. One 2017 study of truck drivers found that those with insomnia were almost twice as likely to have an accident, and three times more likely to be involved in a near miss compared to drivers without insomnia²
• People with insomnia are 9.82 times more likely to develop depression and 17.35 times more likely to suffer significant anxiety³

Insomnia and stress

Sleep is the behavioral and neurological state in which your body rests. It’s essential for proper, healthy functioning of the body’s systems. The average adult needs at least seven hours sleep each night. Those who frequently get less are more likely to suffer from health problems including heart disease, asthma, obesity, depression and diabetes. Despite the undesirable effects, more than a third of adults in the US regularly get by on fewer than 7 hours sleep, and sleep deprivation is becoming a public health epidemic⁴. Worldwide, between 35% and 50% of adults show symptoms of insomnia⁵.

Poor sleep can be caused by many aspects of modern life – backlit computer screens, light bulbs, mobile technology and the blurring of boundaries between work and down-time all result in a chronic imbalance in the autonomic stress response. This “exaggerated and maladaptive neurobiological and cognitive–emotional reactivity to stress” ⁶ is a common marker of insomnia.

Insomnia has major implications for health and quality of life. Every year, around 109,000 road traffic accidents and 6,400 fatal crashes in the US happen as the result of a sleep-deprived driver⁷. Medical costs are high, with 4% of Americans relying on potentially habit-forming hypnotic drugs such as benzodiazepines⁸, which can disturb sleep patterns and produce side effects including withdrawal, suppressed respiration, increased risk of death, depression, and possibly cancer⁹. And sleep deprivation costs the economy billions of dollars in sick leave, low productivity and medical bills¹⁰.

Scientists have suggested that natural interventions such as breathing, relaxation and sleep hygiene techniques¹¹, which all improve sleep quality and duration, may be more effective long-term than the use of hypnotic drugs in addressing the global issue of insomnia.

Is insomnia a breathing pattern disorder?

In 2012, scientists in the US examined the relationship between treatment resistant chronic insomnia and sleep-disordered breathing. In order to gain a clear view of the relationship between breathing and insomnia, patients with obstructive sleep apnea, (OSA) were excluded from the review. Despite this, researchers found that around 90% of awakenings observed in participants were preceded by respiratory-related events¹². They also reported that, although OSA patients had been excluded from the trial, 11 of the 20 participants actually met the clinical criteria for OSA. They either had a high AHI reading (apnea, hypopnea index) or displayed upper airway resistance syndrome – a sleep disorder characterized by the narrowing of the airway, the primary symptoms of which include excessive fatigue and chronic insomnia¹³. These observations suggest a high prevalence of sleep disordered breathing amongst those with insomnia¹².

The studied sample discussed in the review was typical of insomnia sufferers, but it was noted that 55% of them snored, 75% were taking nightly sleep medications and 50% had trauma history¹⁴. The researchers observed that any one of these considerations could contribute to sleep-disordered breathing or awakenings.

Arousal from sleep can make people more vulnerable to ventilatory and upper airway instability too. While more research is needed to confirm the theory, the paper suggests that arousal of the brain and sympathetic nervous system could cause airway instability, prompting sleep-disordered breathing and resulting in awakening and difficulty getting back to sleep.

The review also describes a crossover trial involving patients with mild sleep-disordered breathing, in which those participants who received treatment for their breathing disorder followed by cognitive behavioral therapy displayed better results than those who received the treatments the other way round¹⁵. Researchers concluded that patients with chronic insomnia should be considered for polysomnography to determine sleep-disordered breathing.

Buteyko Breathing as a treatment for insomnia

Common treatment suggestions for insomnia include:

• Improving sleep hygiene
• Using exercise to regulate homeostatic functions
• Reducing light exposure to regulate circadian rhythms
• Reducing stimulants including alcohol and caffeine
• Using relaxation techniques to manage stress¹¹

Some relaxation techniques are known to activate the parasympathetic nervous system’s rest-and-digest mode via the vagus nerve. Others use cognitive-behavioral elements and visualizations of tranquil scenes and places. All of these have been found to help calm the mind and relax the body, addressing certain aspects of insomnia.

One 2019 study looked in detail at the impact of self-regulated slow breathing practice and its benefits for insomniacs¹¹. Although slow, diaphragmatic breathing is the most commonly used technique for insomnia, there has not been much direct research into why it works¹⁶. It has been suggested, however, that autonomic dysfunction plays a part in insomnia. Since slow breathing stimulates the vagus nerve, helping to balance out the activity between the two branches of the autonomic nervous system and increasing resilience against stress, it makes sense that it would improve sleep quality.

Numerous studies have shown that slow breathing at a rate of six breaths a minute optimizes the interaction between heart rate and breathing pattern. Interestingly, the synchronization of breath and heart rate, or cardiac synchronization¹⁷ that occurs during slow-wave sleep helps in the restorative function of sleep¹⁸. It’s also directly associated with an increase in parasympathetic or vagal tone, which in turn aligns the body and brain in a state of relaxation.

Slow, deep breathing techniques form the basis of some of the oldest therapeutic and contemplative practices in the world. There’s a growing weight of evidence showing benefits of slow breathing on stress, asthma, pain and other mental and physical conditions. But there’s very little literature on the effects of slow breathing on insomnia¹¹. The 2019 study suggests that the impact of slow breathing on the nervous system may be a balancing one – the parasympathetic, rest-and-digest system is strengthened, and the overactive sympathetic fight, flight or freeze branch “largely brought about by the frenetic nature of modern life,” is attenuated¹¹. There is empirical evidence that a breathing rate of six breaths a minute (a frequency of 0.1 Hz) is the most effective in combating insomnia¹⁹, because this is the respiratory rate that initiates cardiac synchronicity and enhances parasympathetic activity. Breathing at six breaths a minute improves sleep quality and ease of falling asleep, and enhances the ability to stay asleep¹⁹.

The study also looks at nasal breathing, explaining that breathing through the nose may help to organize brain activity, for example, by exerting control over cortical excitability²⁰. This means that it may be possible to use breath training to alter brain waves (as seen in the increase in delta activity during slow breathing²¹) which has exciting implications for the potential use of breath training in the modulation of sleep.

Buteyko Technique for reducing insomnia

The optimum breathing rate of six breaths a minute is important in addressing breathing pattern disorders. From a biochemical standpoint, it offers the best conditions for blood gas exchange, so as to best oxygenate the cells and muscles. Biomechanically, it engages the diaphragm and reduces the amount of air breathed, alleviating chronic hyperventilation.

The simple exercises that form the Buteyko Technique will teach you to breath slow, light, and deeply through your nose, improving your everyday breathing patterns, and your sleep quality.

Tips to achieve better quality sleep

• Slow breathing: Practice an exercise to reduce your breathing. Place one hand on your belly and the other on your chest. Softly slow your breathing to create a light air hunger. Practice this for around fifteen minutes before bed. This exercise is very helpful in sleep-disordered breathing and can help you to get to sleep more easily.
• Restore full-time nasal breathing: Nasal breathing during sleep is really important. It prevents mouth snoring, sleep apnea and even protects against gum disease. If you frequently wake with a dry mouth in the morning, the chances are you mouth-breathe in your sleep. Try applying MYOTAPE before sleep to help you re-learn habitual nasal breathing. If your nose is congested, use the nose unblocking exercise before taping your mouth. You may also find a nasal dilator like the Mute™ snoring device helpful. Your nose will only ever fully block if you revert to mouth breathing. Once you have restored the habit of nasal breathing at night, you may find you no longer need the dilator.
  N.B. Any child wearing MYOTAPE at night must be able to remove the tape themselves if they need to. Do not use this method on children under five years old, or if your child has a tummy upset or may vomit. Adults should not wear the tape if they are feeling sick or have been drinking alcohol.
• Avoid eating a large meal just before you go to bed. And remember, alcohol is a stimulant. While it may send you off to sleep easily, your sleep quality will be poor.
• The best position to lie in to get a good night’s sleep is on your left side. This reduces ventilation, which makes it less likely that your breathing will be uncontrolled. Equally, lying on your tummy minimizes breathing because of weight of your body. Research has also shown that lying on your left side greatly reduces gastric reflux during sleep.
• Try to keep your bedroom calm, and free from screens and backlit devices. You’re much more likely to get a good night’s sleep if your bedroom is a technology-free zone.
• Check your control pause: By measuring your control pause before bed and again first thing in the morning, you can find out whether you are over-breathing during your sleep. If your control pause is lower in the morning, you have been mouth breathing or breathing too hard at night. If you regularly wake up with breathing difficulties during the night, try sleeping in an upright position. Set an alarm to wake you up every few hours. This will stop you from falling into a deep sleep where your breathing may become uncontrolled. each time the alarm sounds, measure your control pause and practice reduced breathing volume exercises. Once your breathing has calmed down, you can go back to sleep.

References:

1. Wikipedia contributors, “Insomnia,” Wikipedia, The Free Encyclopedia, https://en.wikipedia.org/w/index.php?title=Insomnia&oldid=940644398(accessed February 14, 2020).

2. Garbarino, Sergio, Nicola Magnavita, Ottavia Guglielmi, Michelangelo Maestri, Guglielmo Dini, Francesca Maria Bersi, Alessandra Toletone, Carlo Chiorri, and Paolo Durando. “Insomnia is associated with road accidents. Further evidence from a study on truck drivers.” PLoS one 12, no. 10 (2017).

3. Taylor, Daniel J., Kenneth L. Lichstein, H. Heith Durrence, Brant W. Reidel, and Andrew J. Bush. “Epidemiology of insomnia, depression, and anxiety.” Sleep 28, no. 11 (2005): 1457-1464.