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Sleep Disorders

Chronic Sleep Maintenance Problems

02/17/2006

Question:

I am a 27 year old female with sleep maintenance problems for approximately 8 years. The problem started off little by little starting college, but now it`s pretty stable -- I usually have no problem falling asleep because I`m tired, but I only sleep about 3 hours before I start waking up. I can fall back asleep again, but I`ll wake up again in the next hour, then every 30 minutes, 15 minutes, 5 minutes, and I usually awaken a few minutes before my alarm goes off. I have a relatively regular sleep schedule, and my sleep habits are good. I`m in graduate school now after being out of school for a while, but my pattern of difficulties has remained the same. I`ve tried many medications that have not worked. Most make my muscles relax, but I end up waking up like I always do just not being so able to roll over. Yes, I have had much difficulty with depression and anxiety over the years, and I`ve sought counseling and I`m doing all right. I`m in good health and on no meds. I don`t snore or have apnea, no restless legs, and my sheets aren`t messed up in the morning. What else could there be? Is it really just something that`s kind of all in my head? This isn`t something I`d say I worry about -- in fact I like going to sleep at night. I welcome it because I`m tired, and it`s comfortable! It`s just that I get too tired during the day, and I find myself doing less and less because I know the more I pile on myself the more apt I am to fall asleep (naps, during lectures, too tired for exercise...) I don`t know what else it could be, and I`d appreciate any suggestions. Thank you so much for your time.

Answer:

Waking up in the middle of the night and experiencing difficulty getting back to sleep can be troublesome. As you point out in your question, this is a form of insomnia known as "sleep maintenance insomnia" and may result from a number of varied causes. Some of the more common conditions or problems that may result in sleep maintenance insomnia include breathing disorders in sleep, leg jerks during sleep or wakefulness (known as periodic limb movement disorder or restless legs syndrome, respectively), depression, conditions associated with pain, heartburn, side effects from medications or substances (such as caffeine, alcohol, or nicotine), circadian rhythm disturbances, and a poor sleep environment. It sounds as though you have already thought about and excluded a number of these conditions.

Further history may provide clues to help determine if any of these factors may be playing a role in your case. In addition, some of these conditions require an evaluation during sleep (a sleep study) to completely rule them out. In the absence of finding a secondary cause for the insomnia, some cases are labeled as "psychophysiologic" insomnia (or learned insomnia). In learned insomnia, an individual develops a chronic form of insomnia either as a gradual change in sleep behavior (as you describe) or following a traumatic event that resulted in short-term insomnia. The problem with learned insomnia is that the brain adapts to the notion, often on a subconscious level, that the bed is associated with an inability to sleep. As a result, chronic insomnia develops and specific treatment may be needed. The goal of treatment of this problem is to try to retrain the mind to associate the bed with sleep. This is often accomplished with behavioral therapy techniques (such as "stimulus control" or "sleep restriction") that are beyond the scope of this answer.

Occasionally sleep aids, particularly some of the newer longer acting medications, may be useful in the short term while undergoing behavioral therapy. In order to determine if you suffer from one of the conditions mentioned above, or if there may be another underlying cause for your sleep disruption, you should speak with your physician about your problem. Your physician will ask for additional information that will determine if you need any diagnostic testing, referral to a Sleep Specialist or possibly go directly on to treatment. All of these conditions can be treated to some degree of success and seeking help is reasonable. In the meantime, improving "Sleep Hygiene" can make a dramatic impact in some cases (see the The Rules of Sleep Hygiene).

To learn more about insomnia or other sleep disorders, please visit the website of the American Academy of Sleep Medicine. In addition to information, the website contains a list of Sleep Centers across the country so that you may locate one near you. The American Insomnia Association website also provides information and links to support groups for those with this condition. Good luck and here's to better sleep!

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Response by:

Case Western Reserve University Dennis Auckley, MD
Associate Professor of Medicine
Department of Medicine
School of Medicine
Case Western Reserve University
Dennis Auckley, MD