Democracy Dies in Darkness

ON YOUR MIND

3 ways to stop waking up

frequently during the night
and improve sleep
Frequent wakings can harm your health. Minimize nighttime bathroom breaks,
get used to a CPAP machine if you have sleep apnea, and relax hypervigilance to
sleep better.
Advice by Lisa Strauss
February 3, 2023 at 6:00 a.m. EST

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.

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.

Minimize 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.

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 precipitate 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.

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.

Here are a few tips for converting the machine from adversary to ally:

1. Commit to a temporary trial. You might discover you feel better and can tolerate the CPAP.

2. Familiarize yourself with the machine’s operations to feel less daunted.

3. Practice putting the mask on several times. Adjust the straps, if necessary, for a good fit.

4. Use it for 30 to 60 minutes per day while reading or watching TV. Let the pressure ramp up.
This method can help you overcome anxiety and aversion, and get used to the sensations
associated with use.

5. When you can forget you have it on, repeat the previous step in your bed (not at sleep time). Try
 it on your back and your sides. Figure out how to position your pillows and the hose when you
shift.

6. When you have mastered Step 5, put it on in bed close to sleep time, zeroing the pressure ramp
as often as you like and gradually working toward being able to fall asleep with it. You will have
adjusted to it at higher pressure, and now can enjoy falling asleep with it at low pressure, which
is much easier.

7. Slowly work toward all-night use. Take breaks as needed if you awaken, and put the mask back
on. Focus on something soothing.

8. If you can’t overcome leakage, mask shifting or discomfort, speak with your provider about a
different mask.

9. Clean the machine in the morning, not at bedtime.

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.

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