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Expert advice for anyone who tosses and turns at night.
The Night Waker
Her challenge: After a stressful breakup two years ago, Meredith Crowell, 40, a single real estate property manager and yoga instructor from Boulder, Colorado, would wake up in the middle of the night filled with sadness and anxiety. But even after she felt better emotionally, the sleep troubles continued. Although she typically falls asleep easily around 10:30 p.m., she is wide awake three or four hours later. She falls back into a fitful sleep, then gets up around 6 a.m. to begin her day.
"I never wake feeling well rested, because it feels like I don't get more than about four hours of truly deep sleep," she said.
To no avail, Meredith has tried myriad remedies―warm baths, hot milk, a glass of wine before bed, no food before bed, relaxation techniques, and prescription and homeopathic medicines. She took a prescription medication, but that didn't give her more than four hours of sleep. She even tried taking the medication when she woke in the middle of the night, but that left her too groggy in the morning.
Expert advice: "The good news is that Meredith's insomnia seems to have a clear precipitant―the breakup," said Dr. David Neubauer a sleep-medicine specialist and an associate director of the Johns Hopkins Sleep Disorders Center, in Baltimore.
Neubauer calls her situation "conditioned arousal," which, he says, is common.
"Her sleep problems may have been initially caused by an external trigger, but over time the sleep problems become self-propagating. Eventually she became conditioned to become anxious about her sleep."
Some things that might help:
Cognitive behavioral therapy (CBT) is often used in cases like this, and the experts agree that it could help Meredith.
"CBT aims to stop the behaviors that are perpetuating the insomnia," said Dr. Susie Esthera, a specialist in sleep-disorder medicine at Charlotte Eye, Ear, Nose, and Throat Associates, in Charlotte, North Carolina, and the president-elect of the American Academy of Sleep Medicine.
Typically, a therapist will work with a patient for four to eight weeks―in sessions that last from 30 minutes to two hours―to assess, diagnose, and treat the underlying problem, such as relationship worries. The therapist will teach the patient things like progressive-relaxation techniques and point out actions that are getting in the way of deep sleep, such as rehashing conversations that occurred earlier in the day. (To find a therapist, go to the website of the National Association of Cognitive Behavioral Therapists, at nacbt.org .)
Acupuncture. "Acupuncture may help reduce her anxiety and induce deeper sleep," said Rubin Naiman, the director of sleep programs at the Miraval Resort, in Tucson.
Avoiding wine. "There is a notion that alcohol will help you sleep," Neubauer said. "And while it often does help you fall asleep quicker, your sleep will be more disrupted."
Accepting some awakenings. The experts stress that nighttime awakenings are perfectly normal―much more normal, in fact, than the elusive solid eight hours people think they should be getting. Most people will roll over and go back to sleep, but those with insomnia become conditioned to feel anxious when they awake during the night.
"You need to accept that you will arouse some, so reassure yourself in the middle of the night that nothing catastrophic will happen if you are awake for a while," Esther said.
To that end, she suggests keeping the glaring electric clock off the bedside table.
"Clock watching will only increase your anxiety about being awake," Esther says.
The Early Bird
Her challenge: Brooke Brown, 38, is a married prekindergarten teacher with three children from Wellesley, Massachusetts. Given her round-the-clock proximity to small children (her own are ages 4, 7, and 9), Brooke is understandably exhausted by the end of the day. So much so that she often falls sound asleep as early as 7 p.m. But she is routinely awakened around 2 a.m.―by a child, her husband snoring, or a need to use the bathroom―and never manages to fall back asleep. She lies in bed with her brain in high gear, eventually giving up on sleep and getting out of bed at 5 a.m. to get a jump on her day.
Expert advice: “She is spending too much time in bed,” said sleep-disorders specialist Susie Esther.
Brooke should establish a standard waking time (and stick to it seven days a week), then work backward to figure out what her bedtime should be. So if she wants to get up at 5 a.m., she should plan to be asleep by about 10 p.m.―not 7 p.m.
“She should gradually adjust her bedtime so that she is able to stay awake later, and that will help her body adapt to the new schedule,” Esther said.
To quell Brooke’s middle-of-the-night worrying, Esther suggests that, instead of lying in bed, she get up and do something relaxing, like having a cup of decaffeinated herbal tea.
“Staying in bed and trying to sleep will just wake you up more,” Esther said. “Sleep isn’t something you can ‘try’ to do.”
The Chronic Insomniac
Her challenge: Kristy Lewis, 29, a married homemaker and photographer from Hampton, Virginia, can't remember a time when she didn't have trouble sleeping.
"I thought it was normal to take an hour or longer to fall asleep, but in 2004 my doctor diagnosed me with insomnia," she said.
She also wakes several times during the night and remains awake for anywhere from a few minutes to an hour. She also suffers from restless legs syndrome and frequently talks in her sleep. Sleep medications help to some degree but leave her feeling drowsy the next day. She has also tried practicing yoga, doing vigorous exercise earlier in the day, avoiding caffeine, and reading or writing in a journal before bed.
Expert advice: "I would first want to investigate her restless legs problem," said sleep-medicine specialist David Neubauer.
Restless legs syndrome, which has recently been taken more seriously by doctors, can sometimes be caused by anemia. If blood tests show that Kristy has anemia, iron supplementation could help. If anemia is not the cause, she could ask her doctor about medications like Mirapex and Requip, which are often prescribed for restless legs syndrome. Otherwise, Kristy might consider:
Pay even more attention to her evening routine and her sleep environment.
"Good sleep habits don't necessarily solve sleep problems, but they do create a foundation for improved sleep," Neubauer said.
Good habits include things such as keeping the bedroom cool and dark, using a fan or a white-noise machine to create a blanket of sound, and using the bed exclusively as a place for sleeping―and not for watching television, for example.
Making an appointment at a sleep clinic, which can be a smart step for people with a long history of sleep issues. Most often this involves office visits (which will not necessarily be overnight observations), during which the patient will undergo a physical examination and work with a doctor to assess and diagnose the cause of the sleep problems. (For more information or to locate a sleep specialist near you, go to the website of the American Academy of Sleep Medicine, at aasmnet.org .)
The Hormone Sufferer
Her challenge: Patty Magovern, 53, a married human-resources director from Wall, New Jersey, never had trouble sleeping―that is, until menopause hit last year.
“My whole life, I would fall asleep as soon as my head hit the pillow and sleep through the night,” she says, “but those days are long gone.”
Now, no matter what time she goes to bed, she has difficulty falling asleep and, like clockwork, awakens at 1 a.m. For the rest of the night, she tosses and turns before finally getting up at 6:30 a.m. Taking over-the-counter or prescription medications helps but leaves her feeling logy in the morning rather than refreshed. She doesn’t want to take hormone-replacement therapy to treat her menopause symptoms, including the hot flashes that sometimes disrupt her sleep, because she worries about the risks.
Expert advice: There is some evidence that hormonal changes can have an effect on sleep. If hot flashes are a big issue, sleep-medicine specialist David Neubauer, points to recent studies that have shown that sleeping in a cooler-than-normal room can help prevent them. More advice:
Use caution regarding over-the-counter sleep medications, since they contain some type of antihistamine, which can stay in the body for a long time.
“It takes about 18 hours for your body to clear out 50 percent of the active drug. For most of your waking hours, it will still be in your system, making you drowsy,” psychologist Rubin Naiman said.
Patty might also benefit from taking 0.3 milligram of an over-the-counter melatonin supplement about 20 minutes before bedtime since the production of melatonin (a naturally produced hormone that helps regulate circadian rhythms) drops off as we age.
Go for a checkup.
“Around the time a woman reaches menopause, other risk factors may emerge, such as sleep apnea,” Neubauer says.
Patty should consider that new medications she may be on could also be disrupting her sleep.
Her challenge: Alexandra Acker, 29, a single executive director of a nonprofit organization from Washington, D.C., has suffered from sleep issues on and off since high school, but they became worse when she moved to Washington, D.C., and took a new job.
“My sleep problems are definitely stress-related,” she said.
While she has no trouble falling asleep, she wakes up many times throughout the night and can’t turn her brain off sufficiently to get back to sleep. She lies in bed thinking about work, making mental to-do lists, and even listening to random songs that play in her head. Making matters worse, there’s traffic noise outside the windows of her studio apartment.
Expert advice: “She seems to have a predisposition for insomnia, and for people like her, whenever there are additional pressures, like a new job, the insomnia bubbles to the surface,” said Dr. Gary Richardson, a senior research scientist and a staff physician at the Sleep Disorders Center at the Henry Ford Hospital, in Detroit.
Since Alexandra is probably not going to change her job or leave D.C., she needs to find ways to handle her stress better so that it doesn’t wake her up at night.
“We expect the brain to turn off when we sleep, but it doesn’t do that, and there’s some evidence that in insomniacs, the areas of the brain that control stress stay active at night,” Richardson said.
So rather than lying awake listening to song lyrics and making lists in her head, Alexandra might:
Distract her brain by trying a relaxation technique, like focusing on her breathing.
Working on keeping her sleep environment quieter, such as using an air conditioner or a fan, as well as blackout shades to block street light.
Try wearing earplugs.
The Night Owl
Her challenge: Nicole Williams, 42, a married homemaker and freelance camera-woman from Los Angeles, has always been nocturnal, but the situation has gotten worse since the birth of her child, four years ago. She grows more alert late at night, then stays up until about 3 a.m., watching TV, reading, clearing out e-mail, and organizing things for her family.
Her daughter wakes her up at 7:30 a.m., and Nicole says she then feels “dangerously drowsy, irritated, and exhausted all day long.” She almost never naps and normally uses the time when her daughter is at school to work or get other things done.
Both prescription and over-the-counter sleep medications have worked, but Nicole worries about being groggy in the morning and doesn’t want to become reliant on them. She has also tried aromatherapy, warm drinks before bed, and meditation.
Expert advice: To start slowing down and readying herself for an earlier bedtime, psychologist Rubin Naiman suggests blocking blue light.
“The blue end of the light spectrum―emitted by ordinary lightbulbs, televisions, and computer screens―suppresses melatonin,” Naiman said.
Nicole might consider buying special lightbulbs as well as blue-blocker filters (available at lowbluelights.com) for her TV and computer screen (if she insists on checking her e-mail) and reducing the amount of light in general.
“Being exposed to too much light at night is the environmental equivalent of caffeine,” Naiman said.
So at least two hours before bed, dim the lights. In addition, Nicole needs to find time earlier in the day for catching up on e-mail and organizing.
The Overstimulated Sleeper
Her challenge: Lauren Razzore, 31, a single professor of animation and Web design and freelance designer from Queens, New York, often stays up until midnight or 2 a.m., reading or catching up on work. When she realizes how late it is, she jumps into bed but then is too wound up to fall asleep for another hour or so.
This tendency is now exacerbated by an erratic schedule. Lauren usually teaches four classes a week. On two days, it’s an early-morning class that requires her to rise at 6 a.m. The other days she has afternoon classes, which allows her to sleep as late as she wants. When she does sleep, it’s not always very restorative. She has vivid dreams that she is teaching, and sometimes she wakes up talking aloud.
“I’m exhausted in the morning because I feel like I’ve been working all night,” she said.
Expert advice: “We can’t always design a sleep schedule that fits with our work schedule, and that can especially be a problem for someone with genetic night-owl tendencies,” said physician and sleep researcher Dr. Gary Richardson.
He suggests that Lauren might benefit from careful napping to help balance out her sleep schedule, especially on days when she has to get up to teach an early class. He recommends lying down and relaxing and getting up after one hour, regardless of whether she actually dozes.
“Napping can interfere with nighttime rest if you sleep too much,” he cautions.
And rather than racing to bed in a panic when she realizes how late it is, Lauren needs to set a regular bedtime and develop a relaxing evening ritual, which, ideally, she should begin at least half an hour before getting into bed. This could include things like a warm bath and some reading, with the lights as low as possible.
The Downtime Seeker
Her challenge: Regina Clark, 39, a married assistant professor of journalism from Somerset, New Jersey, stays up until midnight or later to have downtime, even though she knows it’s at the expense of getting a good night’s sleep. (She often needs to be up at 5 a.m.)
When she does lie down, her mind doesn’t stop working, especially now that she is up for tenure at her teaching job and pregnant with twins. When she finally falls asleep, it’s a very light sleep. She’s awakened easily and often by things like her dog’s barking or her husband’s snoring. She normally manages to get about five hours of sleep but feels she needs a solid seven or eight hours to be fully functional.
“I tend to be foggy or hazy during the day, unable to focus clearly or remember things properly, and I know it’s related to not getting enough sleep,” Regina said.
Expert advice: Regina should take 30 minutes or so earlier in the day to do the things that are keeping her up (like checking e-mail and writing lists). Also:
She should ask her husband to have his snoring checked to make sure it’s not a symptom of a more serious problem―and she might try wearing earplugs to block out the noise.
In addition, she can keep the dog out of the bedroom and maybe have her husband agree to get up with their two-year-old baby for a few weeks while she focuses on improving her sleep pattern.
Regina should practice “letting go,” says psychologist Rubin Naiman. He encourages her to work on managing stress by exercising more and, if possible, delegating more at work so she doesn’t feel so overwhelmed.
“We’re such an active, ‘doing’ culture, and then we get into bed and try to ‘do’ sleep,” Naiman said. “You can’t just ‘go’ to sleep, but you can learn to let go of waking.”
The Slow Riser
Her challenge: Elizabeth Marks, 29, a married graduate student from Chicago, struggles with an innate tendency is to stay up till midnight, then hit snooze so many times in the morning.
"The clock has been known to give up," she said.
Even when she feels exhausted all day, she becomes more alert at night. When she does get into bed, it takes her up to an hour to fall asleep. Elizabeth has tried going to bed earlier so she'll have less trouble getting up in the morning, but then she just lies awake. She doesn't drink caffeine, and she reads when she gets into bed, does yoga three times a week, and uses an aromatherapy-oil diffuser in her bedroom.
Expert advice: While avoiding caffeine in the afternoon and the evening is a wise move, physician and sleep researcher Gary Richardson says that having some first thing in the morning can be helpful for people like Elizabeth, who have trouble waking up.
Modulating her exposure to light could reset her internal clock gradually, according to Richardson.
"Too much light at night will push her clock even later," he said, so the key is to keep the lights dim the closer she gets to bedtime.
Elizabeth should also maximize her light exposure first thing in the morning. If she can go outside in bright sunlight for some exercise, that would provide a double whammy of wakefulness.
Taking a melatonin supplement (0.3 milligram before bed) might help Elizabeth if light manipulation isn't enough, Richardson suggests. It may help pull her internal clock to an earlier hour so she can get the sleep she needs.
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