As a psychologist specializing in sleep disorders, I hear this complaint the most from new patients: “I fall asleep okay, but I wake up during the night.”
Everyone wakes up a few times per night. Cycling out of sleep roughly every 90 minutes to two hours is normal. But frequent wakings can affect physical, emotional and mental functioning. We fail to get adequate quantities of the deepest stages of sleep, and react to disruptions with metabolic, inflammatory and stress responses.
Obstructive sleep apnea, periodic limb movements (leg jerks), iron deficiency, hyperthyroidism, gastroesophageal reflux, pain, allergies, asthma, hormonal changes, anxiety, depression and certain medications are some of the main contributors to fragmented sleep.
A related problem for many of my patients is that once their sleep is disrupted — especially if they are startled awake or have a lot on their minds or have already had most of their night’s sleep — they lie awake for long stretches. While I teach methods for returning to sleep, it is always better to prevent unnecessary wakings and full wakefulness.
One of my patients complained of frequent wakings to use the bathroom. After awakening for the last time, she would use the bathroom, and then toss and turn. She would read on her phone for a couple of hours until she had to get up to start her day. She had been diagnosed with apnea, and had a continuous positive airway pressure, or CPAP, machine, but found the mask uncomfortable and would remove it early in the night. Consequently, she was tired during the day and struggled to stay awake in the evenings.
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My patient did not appear to be a candidate for simple behavioral interventions such as compressing her sleep hours, limiting late-day alcohol (whose wearing off precipitates light sleep and wakings), minimizing environmental disturbances (such as snoring spouses and clamorous pets), avoiding lengthy or late naps, facing problems long before bedtime, not eating or exercising late at night, winding down in the pre-bed hours until peaceful, and getting morning sunshine.
Other interventions such as these three less well-known solutions for light sleep and wakings seemed more likely to help. My patient benefited significantly from the first two approaches.
End of carouselMinimize bathroom breaks
There are many reasons for excessive nighttime urination, such as diabetes, apnea, an enlarged prostate, caffeine and Pavlovian conditioning. But there is another potential culprit: circadian rhythm.
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We secrete antidiuretic hormone (vasopressin) throughout the 24-hour cycle, but especially at night, and even more so toward the end of our sleep. This keeps the body hydrated and reduces the need to urinate at night.
If your biological clock is misaligned with your intended sleep schedule — for example, if you are an early bird or night owl trying to sleep on a normal schedule — you may not be secreting enough of the hormone at the appropriate times, causing the need to go to the bathroom.
And ironically, turning on the light each time you have to go may reinforce the circadian issue that is causing the need to go in the first place. Light exposure in the middle of the night sends a “sunlight” signal to the biological clock, which is highly sensitive at that time. And light has an especially potent effect if your eyes are dark-adapted, as they are if you have been asleep.
Strive for darkness at night, or if you need a light for safety, use a dim and reddish (long-wavelength) light in the bathroom. This preserves production of melatonin, a hormone that helps with the timing of sleep. The short-wavelength component of many lights — even when they don’t look blue — suppresses the synthesis and secretion of melatonin.
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To help my patient not fall asleep and wake too early, I suggested exposure to abundant environmental light during the 7 p.m. hour. This would suppress premature secretion of melatonin, which tends to begin two to three hours before natural sleep onset, and would provide a “sunlight” signal. I also asked her to avoid the light from her phone if she woke up early because it was sending that signal prematurely.
Delaying a too-early sleep and wake rhythm can also prevent stress hormones — adrenocorticotropic hormone (ACTH) and then cortisol — from being secreted in the middle of the night, making sleep more restful.
Desensitize yourself to CPAP
My patient also needed to treat her apnea to forestall wakings and the need to use the bathroom. Many people give up on CPAP because both the idea and the physical intrusion of the device can be daunting. They also are not convinced they need it.
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Here are a few tips for converting the machine from adversary to ally:
My patient was able to increase her nightly use of CPAP to about six hours, and felt better for it.
Relax hypervigilance
Some people are on guard duty all night even when any trauma is past. Assuming there is no immediate danger (which should always be addressed first), you can work on feeling safer to sleep better.
This is not a substitute for trauma therapy, but here is one of many methods I teach my patients for feeling safer: Direct this mantra (or one you prefer) toward yourself for a few minutes each day with eyes closed and whenever you feel afraid (including during the night):
May you know that you are safe.
May you know that you are loved.
May you be at peace.
Lisa Strauss, PhD, is a clinical psychologist in private practice in the Boston area. She specializes in sleep disorders.
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