Colin Snow
Sleep is an essential part of our lives, but it can be frustrating when we can't fall or stay asleep. Sleep maintenance insomnia is a type of insomnia where people wake up frequently during the night and have trouble falling back asleep. This can be caused by various factors, including underlying health conditions, medication side effects, stress, and pain. Other reasons for disrupted sleep could be a misalignment between your sleep schedule and your body's natural circadian rhythm, which can be caused by work or school schedules, or even jet lag.
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What You'll Learn
Sleep maintenance insomnia
While the precise cause of sleep maintenance insomnia remains unknown, several factors have been identified that can increase the risk of developing this condition. One factor is age; as people get older, the amount of time spent in deep sleep decreases, which can disrupt the circadian rhythm or sleep-wake cycle. Additionally, women are more prone to all forms of insomnia, especially during menopause when hormonal changes can make it harder to stay asleep. Other factors include mental health conditions such as depression, anxiety, and post-traumatic stress disorder (PTSD), as well as respiratory problems and reduced mobility.
To diagnose sleep maintenance insomnia, doctors may recommend sleep studies, actigraphy, or blood tests to rule out other conditions and identify any underlying problems that may affect sleep. Treatment options for sleep maintenance insomnia include cognitive-behavioural therapy (CBT), which is a specialised form of psychotherapy that addresses thoughts, habits, and behaviours that interact to impact mental health and outlook. CBT for insomnia, or CBT-i, focuses on identifying and addressing patterns that affect sleep, such as sleep hygiene and relaxation techniques. Medications may also be recommended in cases where CBT-i is ineffective.
Additionally, certain lifestyle changes can help improve sleep maintenance insomnia. These include making the bedroom sleep-friendly by keeping it cool, quiet, and dark, avoiding electronic devices before bed, maintaining a regular sleep schedule, and refraining from consuming caffeine, nicotine, and alcohol, especially close to bedtime.
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Circadian rhythm disorders
When an individual has an underlying circadian rhythm sleep disorder, their desired sleep schedule might be inconsistent and shift over time or not match the light-dark schedule of the area in which they live. Blind people who cannot perceive light are most likely to develop the disorder since their circadian rhythms cannot be influenced by light exposure. Less commonly, the disorder develops in people who are sighted but have unusually long circadian rhythms.
There are six types of circadian rhythm sleep disorders, also known as CRSDs. The four main types are delayed sleep phase disorder, advanced sleep phase disorder, non-24-hour sleep-wake disorder, and irregular sleep-wake rhythm disorder. In delayed sleep-wake phase disorder (DSWPD), a person goes to sleep and wakes up much later than normal or than they would like to. With non-24-hour sleep-wake rhythm disorder (N24SWD), an individual's circadian rhythm extends slightly beyond the regular 24-hour schedule. This leads to bedtimes and wake times that gradually shift later each day. Shift work sleep disorder can develop in people who work variable schedules or overnight hours. As a result, they experience symptoms such as disrupted sleep with associated insomnia, tiredness, and the tendency to fall asleep at unwanted times.
CRSDs can be categorized into two groups based on their underlying mechanisms. The first category is composed of disorders where the endogenous oscillator has been altered, known as intrinsic type disorders. The second category consists of disorders in which the external environment and the endogenous circadian clock are misaligned, called extrinsic type CRSDs. To be diagnosed with CRSD, there must be a misalignment between the timing of the circadian oscillator and the surrounding environment, or a failure in the clock entrainment pathway.
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Idiopathic hypersomnia
IH significantly impacts the quality of life of those affected. Individuals with IH may spend most of their day sleeping or thinking about, craving, or fighting the urge to sleep. They may require one or more long naps (lasting an hour or more) during the day and often need additional sleep, exceeding the average person's sleep duration. Waking up is particularly challenging for people with IH, who may require multiple alarms and established morning routines to wake up for daily commitments.
The condition is similar to narcolepsy in terms of excessive sleepiness but differs in several key aspects. Unlike narcolepsy, IH does not typically involve sudden sleep attacks or cataplexy, the loss of muscle control triggered by strong emotions. Additionally, while naps are refreshing for people with narcolepsy, they are often unrefreshing for those with IH and may even need to be avoided due to problematic sleep drunkenness. Sleep drunkenness, a period of confusion and sleepiness upon awakening, is a common issue for individuals with IH.
The cause of IH is unknown, and its diagnosis can be challenging. The condition is considered rare, with estimated prevalence rates ranging from one in 50,000 to one in 3,000 people. However, these estimates may be uncertain due to the potential for misdiagnosis. Lifestyle changes, such as avoiding alcohol and certain medications, and wake-promoting agents like pitolisant and solriamfetol, can help manage IH symptoms.
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Respiratory issues
Another respiratory issue that can disrupt your sleep is asthma. Asthma is caused by inflammation in the lungs, leading to breathing difficulties. Certain factors, such as sleeping position or mucus buildup in the throat, can trigger asthma symptoms during sleep, causing coughing and difficulty breathing. Allergies can also play a role in asthma and respiratory issues. Allergic rhinitis, triggered by allergens like dust, mold, pollen, or pet dander, can irritate the throat and lead to congestion and coughing.
Additionally, conditions like pulmonary embolism, COPD, and pneumonia can contribute to respiratory distress and disrupted sleep. Pulmonary embolism occurs when a blood clot forms in the lungs, causing symptoms like chest pain, coughing, and swelling. COPD is characterized by blocked or narrowed airways, resulting in symptoms such as wheezing, coughing, and tightness in the chest. Pneumonia, caused by viruses, bacteria, or fungi, can also lead to respiratory issues and sleep disturbances.
If you suspect you have a respiratory issue that is impacting your sleep, it is important to consult a healthcare professional. They can perform a physical exam, evaluate your symptoms and medical history, and recommend appropriate testing or treatment options to improve your sleep quality and respiratory health.
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Stress and anxiety
Sleep and anxiety are closely linked. Anxiety can cause sleeping problems, and insufficient sleep can worsen anxiety, creating a vicious cycle.
Anxiety is a natural human response to stressful or dangerous situations. It causes the body to release hormones that help you react quickly to escape harm. However, chronically high levels of these hormones, especially before sleep, can make it hard for your body to relax and fall asleep. If you do fall asleep, you may wake up during the night with stressful or worrisome thoughts and be unable to fall back asleep.
People with anxiety disorders are much more likely to have sleeping problems when facing stress. Research suggests that anxiety can affect rapid eye movement (REM) sleep, the phase of sleep when you tend to have vivid dreams. If you have anxiety, these dreams may be disturbing or turn into nightmares that wake you up. Sleep deprivation can also cause an unusual increase in noradrenaline levels, which is a hormone involved in the fight-or-flight response that keeps you awake.
Sleep anxiety is a common characteristic of insomnia, where you begin to experience anxiety during the day and night about poor sleep, leading to another night of bad sleep. Sleep anxiety can affect adults, teens, and children. It can also be caused by other underlying mental health disorders, such as panic disorder, post-traumatic stress disorder (PTSD), and depression.
If you are experiencing sleep issues due to stress and anxiety, there are several strategies you can try:
- Relaxation techniques: Try deep breathing, mindfulness meditation, progressive muscle relaxation, or guided imagery to relax your mind and body before bed or when you wake up during the night.
- Cognitive Behavioral Therapy (CBT): This type of therapy can help you recognize thoughts that keep you awake and redirect your thinking. It often includes relaxation strategies and mindfulness techniques.
- Medication: Anti-anxiety medications can be prescribed by a mental health professional to help manage your symptoms.
- Exercise: Physical activity earlier in the day can reduce anxiety symptoms and improve sleep.
- Sleep hygiene: Establish a consistent sleep schedule, avoid electronics and screens before bed, create a comfortable sleeping environment, and limit caffeine intake.
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Frequently asked questions
Waking up in the middle of the night is normal. Most people experience mini-awakenings without even noticing them. However, persistent trouble sleeping could be due to:
- Sleep maintenance insomnia, which can be caused by health conditions, medications, or stress.
- Sleep inertia, a brief time during the transition from sleep to being awake, which can make you feel groggy and disoriented.
- A misalignment between your sleep schedule and your body's circadian rhythm due to work or school schedules, jet lag, or changes to your body's hormones.
- Respiratory issues, pain, or illnesses such as asthma, sleep apnea, allergies, or neurological conditions.
- Stress, anxiety, or other mental health conditions.
If you are concerned about your sleep, consider speaking to a doctor or sleep expert for advice.
If you wake up and can't fall back asleep within 20 minutes, get out of bed and go to another room. Sit in a comfortable chair and read a book or listen to quiet music. Do something relaxing that will take your mind off stressful thoughts.
Try to maintain a consistent sleep schedule by getting up and going to bed at the same time every day. Avoid napping, sleeping in, or going to bed early the next night.
If you think your sleep issues are due to a health condition, speak to a doctor. They can evaluate your symptoms, perform an exam, and recommend testing to diagnose or rule out any potential sleep disorders or underlying health issues.
