Sleep Onset Insomnia: 8 Do’s and Don’ts for Better Sleep

Sleep-onset insomnia—trouble falling asleep at the beginning of the night—has been one of the biggest challenges in my life. By now, having gone through insomnia therapy and spent decades observing how changes in behavior and the environment affect my sleep, I know what I need to do—and what not to do—to get the best night’s sleep I can.

If you’ve got sleep-onset insomnia, here are 8 do’s and don’ts that may help to regularize your sleep.

Sleep-Onset Insomnia can be minimized by changing habitsSleep onset insomnia—trouble falling asleep at the beginning of the night—has been one of the biggest challenges in my life. By now, having gone through insomnia therapy and spent decades observing how changes in behavior and the environment affect my sleep, I know what I need to do—and what not to do—to get the best night’s sleep I can.

If you’ve got sleep onset insomnia, here are 8 do’s and don’ts that may help to regularize your sleep.

Do These Things to Fall Asleep Faster:

  • Get up at the same time every day, including on weekends. This one of the hardest—but most important—habits to adopt, and frankly it’s one I struggle with to this day. Especially after a late night or two, it’s hard to stay the course and get up at 6 a.m. But if I don’t stick pretty rigidly to what I’ve decided is the best rise time for me, if I allow myself more than a little flexibility, my sleep goes off the rails. Making up lost sleep at the beginning of the night, rather than at the end, is by far the easier course.
  • Sign off all devices with screens at least an hour before you usually go to bed—and that includes eReaders and smartphones. If you’re a news junkie like me, watching out for headlines so you can read new stories the minute they come out, this can feel like major deprivation. Yet the light emitted by these screens has been shown time and again to interfere with melatonin secretion, delaying sleep onset—exactly what none of us wants.
  • Get regular exercise and eat regular meals. Aerobic exercise late in the afternoon works best for me, and adhering to my daily workout routine has become so ingrained that when I miss my exercise fix my body doesn’t feel like winding down at night. Regular exercise and regular meals—in fact, regularity in almost all activities because it helps regularize internal circadian rhythms—will likely help you sleep better.
  • Pay attention to the temperature of your bedroom and make adjustments early if necessary. The ideal temperature for sleep is a few degrees lower than what you’re comfortable with during the daytime. So, particularly as research suggests that people with insomnia may have trouble down-regulating internal body temperature, get the window fan going well before bedtime so that by the time it comes you’re not too hot to sleep.

Don’t Do Things That Perpetuate Trouble Falling Asleep:

  • Don’t watch the clock at night. Nothing triggers my anxiety about sleep as much as glancing at the clock at, say, 1 a.m. and realizing I’m not sleepy yet. This is one association—between the clock registering time late at night and trouble sleeping—that I’ve never gotten rid of despite my improved sleep. Turning my clocks toward the wall after about 10 p.m. solves the problem, and it might help you sleep better, too.
  • Don’t jump in bed the minute you get home even if you get home late. For me, heading to bed right away gives my brain permission to trot out all the unfinished business of the day and chew on it while I toss and turn in bed. If you get home late, put on your pajamas, brush your teeth and so forth. But then take 20 or 30 minutes to unwind—read a book or listen to music—before you hit the sack.
  • Don’t stay in bed if, after 15 or 20 minutes, you find you can’t sleep. For me, remaining in bed almost always results in continuing wakefulness, exactly the opposite of what I want. Instead, get up and do some quiet, low-stimulation activity—page through catalogs, make a travel list, cull your bookshelves—until you feel sleepy. Then head back to bed.
  • Don’t beat yourself up—when you’ve adopted all the sleep-friendly habits you possibly can—if you’re still feeling wakeful when your normal bedtime comes around. There’s a genetic component to insomnia, and there are genetic factors that determine sleep onset latency. One day, it may be possible to alter gene expression and so improve sleep. For now, acceptance of the occasional bad night is something it pays all of us to learn to do.

If sleep onset insomnia is your problem, what behaviors seem to make it worse and which behaviors, if any, seem to help?

Off-Label Prescribing for Insomnia: What to Expect

Several drugs approved for insomnia are in the doghouse these days, and physicians are doing a fair amount of off-label prescribing. What medications should we expect to be prescribed in lieu of zolpidem (Ambien) and temazepam (Restoril)?

Using a “translational approach,” McGill University researchers have reviewed a host of medications with sedative properties and found the evidence base for some is stronger than for others. Here are the drugs they’ve found are most likely to work.

Insomnia treated with sleeping pill substituteSeveral drugs approved for insomnia are in the doghouse these days, and physicians are doing a fair amount of off-label prescribing. What medications should we expect to be prescribed in lieu of zolpidem (Ambien) and temazepam (Restoril)?

Using a “translational approach,” McGill University researchers have reviewed a host of medications with sedative properties and found the evidence base for some is stronger than for others. Here are the drugs they’ve found are most likely to work.

Why Not Stick With the Tried and True?

Z-drugs such as zolpidem and benzodiazepines such as temazepam may be fine for short-term or occasional use. But lots of people who take these sleeping pills go on to become chronic users.

This can cause problems. People who take a Z-drug or a benzodiazepine nightly for months and years often experience adverse effects: a decrease in deep (or slow-wave) sleep and/or cognitive and motor impairments the next day. Some develop drug dependency.

The Off-Label Prescribing Dilemma

So where’s the next generation of sleeping pills in line to replace the ones we’re using now? A few new drugs are in the pipeline, but none I’m aware of are going up for FDA approval soon. As often happens, we’ve got to fall back on drugs already approved to treat other health problems. It’s perfectly legal for doctors to prescribe such drugs off label as treatment for insomnia.

The problem lies in knowing which other drug(s) to choose. Medications approved for insomnia have demonstrated their efficacy in at least two randomized clinical trials (RCTs) conducted on people with insomnia (and no other related condition). Compared with placebo, they’ve been found to significantly improve sleep. Medications approved for other health conditions—such as depression, anxiety, or neuropathic pain—may have known sedative properties. But in many cases they haven’t been tested for efficacy on people with simple insomnia.

A Translational Approach

In an in-depth review paper published this month in Pharmacological Reviews, the McGill University researchers propose instead using a translational approach to evaluate these drugs for efficacy in treating insomnia. This involves integrating what basic scientific research has shown about a drug’s pharmacology and mechanism of action with clinical data and current medical practice.

Using this approach, the researchers went on to identify medications most likely to serve as effective alternatives for Z-drugs and benzodiazepines. Here they are:

Drugs That Act on the Melatonin System

1. Prolonged-release melatonin (PRM): FDA-approved dietary supplement sold over the counter in the United States; sold as a prescription drug (2 mg/day) in Europe. “Good evidence,” based on 4 RCTs, that PRM is effective for insomnia disorder in adults over age 55 (particularly in reducing time to sleep onset). There’s no evidence that PRM is effective for younger adults with insomnia. (Caveat: The quality control of dietary supplements sold in the United States is not nearly as reliable as the control of prescription medications. Your physician may be able to steer you toward a reliable brand.)

2. Ramelteon (Rozerem): FDA-approved drug for treatment of sleep onset insomnia. “Strong evidence,” based on 2 meta-analyses, that the drug reduces subjective time it takes to fall asleep but no evidence that it helps people sleep longer.

3. Agomelatine (Melitor): Not available in the United States but approved for treatment of major depressive disorder in Canada and Europe. “Good evidence,” based on 1 review and 2 RCTs, that this drug reduces sleep latency in people with depression. Unlikely to improve sleep in people with simple insomnia.

A Drug That Acts on the Orexin System

4. Suvorexant (Belsomra): FDA-approved drug for treatment of insomnia disorder. “Strong evidence,” based on 2 systematic reviews, that the drug reduces insomnia symptoms at doses of 15 mg and higher. It purportedly increases total subjective sleep time and decreases subjective time to sleep onset. (Caveat: Because this drug is a relative newcomer, less is known about its real-world effectiveness and actual side effects. For more information, read my earlier post about Belsomra and take a look at the reader comments.)

Sedating Antidepressants

5. Low-dose doxepin (Silenor): FDA-approved drug for treatment of sleep maintenance insomnia that acts on the histamine system. “Strong evidence,” based on 1 systematic review, that this drug enhances sleep maintenance by reducing nighttime wake-ups. It has not been found to cut down on time to sleep onset.

6. Trazodone: FDA-approved drug for treatment of depression. At low doses, commonly prescribed off label for treatment of insomnia. It acts on the histamine, serotonin, and catecholamine systems. “Good evidence,” based on 2 RCTs, that trazodone reduces insomnia symptoms in people who are taking selective serotonin reuptake inhibitors (SSRIs) to manage depression. This is the only conclusion drawn by the McGill researchers about trazodone. It does not account for the drug’s great popularity with physician prescribers, who for decades have been prescribing trazodone for insomnia rather than Z-drugs and benzodiazepines.

More on Trazodone

So I looked at another paper, this one a systematic review of trazodone for insomnia published in Innovations in Clinical Neuroscience in August 2017. From a pool of 45 studies (the inclusion criteria were evidently less stringent for these researchers than for the McGill researchers, who reviewed 16 studies of trazodone), the second team of researchers concluded that trazodone “is a generally safe therapeutic that has been repeatedly validated as an efficacious treatment for insomnia, particularly for patients with comorbid depression,” with some evidence that it decreases sleep latency, increases sleep duration, and improves sleep quality. Side effects, which may show up in people taking doses higher than 100 mg, include daytime sleepiness, headache, and hypotension, increasing the risk of falls.

The evidence base for trazodone’s effectiveness as a drug for people with simple insomnia is sparse yet suggestive of similar benefits, the second research team reports. (Results of a recent 6-week clinical trial comparing 3 active insomnia treatments—behavioral therapy, zolpidem, and trazodone—are not yet available. Stay tuned.)

An Anticonvulsant Drug

7. Pregabalin: FDA-approved drug for treatment of neuropathic pain, seizures, and fibromyalgia. There is “good evidence,” based on 2 review papers, that pregabalin is effective in reducing symptoms of insomnia in generalized anxiety disorder. There is also “good evidence,” based on 1 review, that the drug is effective in reducing symptoms of insomnia in fibromyalgia. But no evidence base for pregabalin as a treatment for simple insomnia exists.

The medical treatment of insomnia has always been problematic, even more so in the past than today. While your physician may be reluctant to keep writing prescriptions for zolpidem, other, possibly safer medications may be available when behavioral treatments for insomnia don’t suffice.

Was My Insomnia Due to Lack of Light?

A daily routine and daily exposure to sunlight help regulate sleep. Research backs this up and I see it in myself. My best sleeps come after days when I get up and out and do the things I do at the usual time.

Last night my sleep went off the rails, and I’m convinced the problem was at least partly related to light. Let me explain.

Insomnia can develop with too little exposure to daylightA daily routine and daily exposure to sunlight help regulate sleep. Research backs this up and I see it in myself. My best sleeps come after days when I get up and out and do the things I do at the usual time.

Last night my sleep went off the rails, and I’m convinced the problem was at least partly related to light. Let me explain.

An Unusual Tiredness

My husband and I were viewing old slides last night, and around 9 p.m. I complained about how tired I was.

“Why?” he asked. Normally at 9 p.m. my evening has barely begun.

I couldn’t explain it. I’d gotten up at the regular time, had coffee, eaten regular meals. Worked in the morning, exercised late in the afternoon. Had a glass of wine before dinner and a decent night’s sleep the night before. Nothing that came to mind could explain how really bone tired I felt.

Staving Off Sleep

Even so, I didn’t go to bed right away. If I’ve learned anything about sleep, it’s that going to bed early can start people like me on a path to perdition. It can lead to:

  • Sleep onset insomnia, or trouble falling asleep at the beginning of the night
  • Sleep maintenance insomnia, or broken sleep with awakenings every hour or two
  • Early awakening insomnia, or waking up in the twos, threes, or fours and being unable to fall back to sleep

So tired though I was, I headed for my favorite easy chair, where I typically read for a couple hours until I’m sleepy enough to fall asleep. Then at some point I went to bed.

A Short Night—Or Was It?

The next thing I knew I woke up in the dark and it felt like morning. I hurried to turn off the alarm clock because my husband was going to sleep in. But when I looked at the time (my clock stays dark at night except when I press the button on top) I saw it wasn’t even close to 5:30, my normal wake-up time. It was only 2:15.

So I went back to bed. At the next awakening, I asked my husband what time it was and he whispered it was almost 5:30. I turned off the alarm.

Only it wasn’t 5:30, and I didn’t turn off the alarm, I later learned from my husband. That whispered exchange must have been a dream. Because when I went downstairs and turned on a light, the clock on the stove said 4 a.m.

What the heck?!

I’d thought my early awakening insomnia was a thing of the past. It was so far from normal now that I was determined to parse it out.

Reconstructing My Day

Two clues lay beside the easy chair where I sat down to read last night.

  • My book: It was open two pages beyond the bookmark, where I’d stopped reading the night before. Guess I didn’t read for very long!
  • Medicine I take every night to help with digestion: Two capsules lay on the desk beside the chair together with a full glass of water, untouched.

Obviously I’d fallen asleep in my chair way earlier than usual. But what had knocked me out so quickly and completely that I forgot to take my medicine? Read just two pages when normally I’d read for at least two hours?

Was Lack of Light the Culprit?

Suddenly it came to me. I had done something out of the ordinary in the middle of the afternoon. I went to a concert, where for two hours I sat under low light listening to Haydn string quartets.

That wasn’t all: the first violinist was super-animated as he played and kept swinging his feet up into the air. Every time those feet came off the ground I thought of a plane taking off, and that image juxtaposed onto the Haydn was jarring. I decided to close my eyes—and kept them closed for the rest of the concert.

So for two hours in the afternoon, at a time when my brain would normally be exposed to light, I sat in near-total darkness. That, added to our half-hour session viewing slides in a dark living room, might have affected my body clock, causing sleepiness to occur earlier than usual and early morning wake-ups.

Bright Light Exposure: Rules to Live By

As ubiquitous as it is, light might not seem like it would have much impact on sleep. But it does. People contending with circadian rhythm disorders have to pay special attention to light, and light or a lack thereof may figure in insomnia, too. Keep these things in mind:

  • Lack of sufficient light exposure during the daytime tends to have a negative effect on sleep duration and sleep quality. Get exposure to sunlight every day by spending time outside or inside near a window.
  • Exposure to bright light early in the morning will help you fall asleep earlier.
  • Exposure to bright light in the evening tends to delay the onset of sleep.

 

Six Tips for Overcoming Sleep Onset Insomnia

Poor sleeping conditions such as those found on planes can interfere with anyone’s sleep. But sleep onset insomniacs may find them particularly challenging, accustomed as we are to not falling asleep very quickly and being bothered by things that other sleepers readily tune out.

Why is it so hard for some insomniacs to fall asleep and what can help? Following are six ways to hold sleep onset insomnia at bay.

Poor sleep conditions compound the problem of sleep onset insomniaIt’s been 10 years since I experienced persistent sleep onset insomnia, but I was reminded of what my nights used to feel like when recently I took a red-eye flight on Spirit Airlines.

Conditions on that plane were not conducive to sleep: seats locked in the upright position; flight attendants whose nattering could be heard over the noise of the engines; dim lighting rather than darkness; kicks to my seat as the 6-footer behind me shifted around in his coach class cubicle; turbulence. I didn’t sleep a wink.

Conditions like these can interfere with anyone’s sleep. But sleep onset insomniacs may find them particularly challenging, accustomed as we are to not falling asleep very quickly and being bothered by things that other sleepers readily tune out.

Why is it so hard for some insomniacs to fall asleep and what can help? Following are six ways to hold sleep onset insomnia at bay.

What Brain Waves Reveal About Insomnia

Research has shown that people with insomnia have a different pattern of cortical activity as we’re drifting off to sleep. Compared with good sleepers, insomniacs are more prone to high-frequency brain waves in the sleep onset period. Once sleep onset has occurred, delta, or slow, waves take longer to appear. This is often taken as evidence of hyperarousal. At night, and possibly during the daytime as well, people with insomnia have higher levels of cortical arousal.

Results of recent study argue otherwise. Here, in the sleep onset period, sleep onset insomniacs were found to experience less high-frequency brain activity than sleep maintenance insomniacs (those who tend to wake up in the middle of the night). But the high-frequency activity in the sleep onset insomniacs took longer to decline. Authors of this study suggest that sleep onset insomnia may be the result of “some form of fast wakefulness inhibition” rather than an expression of cortical hyperarousal.

Relief for Sleep Onset Insomnia

Whatever may be the case, habits I’ve developed over the past 10 years enable me to fall asleep quickly now (barring nights when I’m trying to sleep on a plane). They may help you, too:

  1. Adopt a regular sleep schedule. Be especially regular about getting up at the same time every day—even on weekends. This can be a challenge if you have an erratic daytime schedule or an active social life. If you find you’re really sleepy, catch up on sleep by allowing yourself to go to bed somewhat earlier than normal rather than sleeping in late. The problem with sleeping much later than usual to catch up on sleep is that it sets you up for trouble falling asleep the next night.
  2. Break the association between your bed and wakefulness by reserving your bed (and the bedroom) for sleep and sex. Reading, TV and movie watching, surfing the net, playing video games—all this should happen outside the bedroom. Only go to bed when you’re sleepy enough to fall asleep.
  3. Exercise late in the afternoon or early in the evening. Exercise warms your body up. This triggers an internal cooling mechanism, and when your body is cooling down it’s easier to fall asleep. Aerobic exercise is best but rigorous strength training may work as well.
  4. Observe a wind-down routine in the hour leading up to bedtime. Have the same routine—shower, put on pajamas, brush teeth, read or look at picture books—every night. Your brain will learn to expect that this sequence of activities ends in sleep.
  5. If clock watching at night makes you anxious, turn your clocks to the wall starting at about 9 or 10 p.m. Use a backlit alarm clock on your bedside table—the kind that stays dark at night except when you press the button on top.
  6. If you have to fly at night, arm yourself beforehand with all the accoutrements I forgot to pack in my carry-on: neck pillow, eye mask, earplugs. As for Spirit Airlines, they may say they’re the company with the newest fleet of planes, but seats that keep you locked in an upright position do not lend themselves to a good night’s sleep!

If you often fly at night, what measures do you take to get a decent night’s sleep?

11+ Nighttime Activities for Sleep Restriction

Here’s a complaint I often hear from insomniacs going through sleep restriction therapy: it’s hard to stay awake until bedtime. A related frustration comes with suddenly having extra time on your hands.

“I don’t know what to do with myself till 2:30 in the morning!” an insomnia sufferer groused to me.

Here are variations on 11 activities aimed at keeping you awake until the clock says it’s time to head to bed.

Sleep restriction less difficult with enjoyable activities that keep you awakeHere’s a complaint I often hear from insomniacs going through sleep restriction therapy: it’s hard to stay awake until bedtime. A related frustration comes with suddenly having extra time on your hands.

“I don’t know what to do with myself till 2:30 in the morning!” an insomnia sufferer groused to me.

Here are variations on 11 activities aimed at keeping you awake until the clock says it’s time to head to bed.

A Trivial Topic? Think Again

Sleep restriction therapy involves first restricting your time in bed to just the number of hours you’re actually sleeping. Then you gradually add time in bed until you find your ideal sleep window. Normally, this means starting therapy with a later-than-usual bedtime, an earlier-than-usual rise time, or both.

If you’re new to sleep restriction, planning what to do in the run-up to a later bedtime may seem unnecessary.

“I’ll read,” you say, “I’ll watch TV, I’ll catch up with friends on Facebook. I’ll do what I always do at night, only I’ll stay up longer.”

Sticking to the familiar may not work and here’s why:

The first week you’re restricting your sleep you’ll probably feel somewhat sleep deprived. If even mild sleep deprivation is involved, passive activities like watching TV and reading can lead to nodding off well before the prescribed bedtime. This interferes with establishing a regular sleep schedule, which is one thing you’re trying to accomplish. The more you stick to your prescribed bed and wake times, the quicker the therapy will take effect.

Devices with screens (computers, iPads, iPhones) emit blue light, which blocks secretion of the sleep-friendly hormone melatonin. It’s helpful to install an app called f.lux or wear blue-blocker glasses if you use devices at night. Even so, being wedded to the screen in the hour leading up to bedtime is not a good idea, especially for people with sleep onset insomnia (people whose insomnia occurs at the beginning of the night).

Other Constraints on Nighttime Activities

Evening activities have to be quiet unless you live alone. Playing the saxophone may be fun for you but obviously not for other members of the household.

Evening activities can’t require a lot of physical or mental stamina. By then you’re usually low in the tank.

A walk outside might have appeal. But depending on who you are and where you live, it may not be safe to leave home after dark.

The Special Challenge of Sleep Anxiety

What to do in the run-up to bedtime can be especially challenging for sleep onset insomniacs, whose anxiety about sleep tends to escalate the later it gets. Clock watching adds to (or is a part of) that sleep-related anxiety. When undergoing sleep restriction there’s no getting around use of the clock for information about when it’s OK to go to bed.

Waiting until anxiety sets in to decide what to do can be risky. A glass of wine? A sleeping pill? You’re off the rails before you’ve even begun. Why add stress to the sleep restriction process by waiting too long to decide what you’re going to do in the extra time you’re up?

Take it from one who’s been there twice and who, knowing what she knows now, would do it somewhat differently. In the week before you start restricting your sleep (as you’re collecting information about your sleep and recording it in your sleep diary), come up with a list of activities you’re going to do when restriction begins, acquiring any supplies you’ll need in advance. Ideally, these activities should (a) be somewhat enjoyable (or at least tolerable), (b) offer mild mental stimulation, and/or (c) involve some movement.

This list of activities is hardly comprehensive. But maybe it will motivate you to come up with other activities that would suit you as well or better.

  1. Do (or Take Up) an Art or Craft:

  • Needlework (quilting, knitting, crocheting, embroidery).
  • Jewelry or beadwork.
  • Woodworking or leatherworking
  • Calligraphy.
  • Origami.
  • Sewing. Lay out a pattern and cut the fabric.
  • Any artistic activity, such as sketching or watercolor painting, as long as it doesn’t require much clean up.
  1. Make Lists:

  • To-do lists and grocery lists.
  • Travel checklists for different kinds of trips (road trips, air travel [overseas and domestic], business trips, camping.) Printed out before each trip, they make packing a lot easier.
  • Gift lists. Avoid panic during the holidays and at birthdays and other special occasions.
  • A bucket list. Think of everything you’d like to see and do while you’re still able to do it.
  1. Organize or Reorganize:

  • Your tool bench.
  • Your jewelry box(es).
  • Your music. If you have CDs, tapes, albums, or sheet music, arrange them by style, period, composer, or instrument.
  • Your herbs and spices. Group them as powders, whole spices, and herbs, or arrange them alphabetically.
  • The garage or the basement.
  1. Sort and Discard:

  • Books. Do one shelf at a time, separating them into keepers, throw-aways, and give-aways.
  • Clothing in closets and drawers.
  • Old photos. Put the ones you want to keep into albums or photo boxes.
  1. Redecorate:

  • Your walls. Take down wall art and replace it with other paintings, photos, prints, or posters.
  • Your shelves. Replace pottery and art objects with others.
  1. Bake Cookies or a Coffeecake.

  2. Do Light Housework:

  • Dust furniture.
  • Fold or iron clothes.
  1. Prepare for the Day Ahead:

  • Set the breakfast table.
  • Pack lunches.
  • Do prep work for the evening meal.
  1. Do Things You Enjoyed in the Past:

  • Play Solitaire.
  • Do a thousand-piece jigsaw puzzle.
  • Get out a telescope, look at the stars, and identify constellations.
  • Gather every small thing you’ve collected outdoors—flowers, nuts, leaves, shells, stones, feathers, pine cones—and look at them under a microscope.

The following two categories of activities may be too passive for some people but could work if combined:

  1. Look at Publications with Images:

  • Art books.
  • Coffee table books.
  • Catalogs.
  • Family albums.
  • Cookbooks. Use a post-it note to mark every recipe you want to try out.
  1. Using Headphones, Listen to:

  • Music.
  • Books on CD.
  • A podcast. (But avoid looking at screens.)

Before you start to restrict your sleep, make a list of activities you’re going to do in the run-up to bedtime. And who knows? You might even enjoy some of that extra time awake.

If you’ve gone through sleep restriction, what activity did you find was most helpful in keeping you awake till bedtime?

Q&A: Can’t Sleep Due to Temperature Sensitivity

A reader named Gunjan recently asked a question about trouble sleeping due to temperature changes at night. Here it is, lightly edited:

“It seems my body is very sensitive to temperature while I am sleeping. Many times it has happened that I went to bed at an optimal temperature. But as soon as my body sleeps, I wake up feeling too cold. Then I go to bed after switching off the fan or covering myself with the bed sheet but then I can’t sleep because I’m too hot. This is quite frustrating. . . . Does anybody . . . have any help to offer?”

Insomnia sufferers may have increased temperature sensitivity at nightA reader named Gunjan recently asked a question about trouble sleeping due to temperature changes at night. Here it is, lightly edited:

“It seems my body is very sensitive to temperature while I am sleeping. Many times it has happened that I went to bed at an optimal temperature. But as soon as my body sleeps, I wake up feeling too cold. Then I go to bed after switching off the fan or covering myself with the bed sheet but then I can’t sleep because I’m too hot. This is quite frustrating. . . . Does anybody . . . have any help to offer?”

Insomnia and Thermosensitivity

Insomnia may have something to do with compromised thermoregulation, but the issue has not been fully investigated, say authors of a paper on sleep and thermosensitivity. Evidence shows that older adults may have an impaired ability to recognize the most comfortable temperature for sleep, and this may relate to abnormalities in the area of the brain that evaluates comfort. Not much else is known.

But I’m never surprised when people complain of trouble sleeping related to temperature sensitivity. I have the problem myself. I’ve gone to bed in very hot and very cold situations and lain awake for a good chunk of the night. Like Gunjan, I regularly have to make small temperature-related adjustments in the middle of the night. Now, with some nights warm and others cool, is the season when it’s trickiest to get it right.

Temperature Changes at Night

Core body temperature varies by about 1.5 degrees Fahrenheit over the course of the 24-hour day. From a temperature high in the evening, it descends and reaches its low point some 1 to 3 hours before normal wake-up time. If you keep the bedroom windows open at night (a cool bedroom is good for sleep), the room temperature will likely drop as well. The combination of internal and environmental temperatures falling could easily explain why you might wake up feeling cold at night.

Covering yourself with a blanket or a bed sheet is the obvious way to make yourself comfortable enough to get back to sleep. But what if, like Gunjan, you then feel too hot?

Covering up can create a closed system where, once the skin temperature has risen enough to dilate the blood vessels close to the skin, the body heat then released has no place to go. It’s similar to the situation created by an electric blanket. The blanket continues to add heat to the body, increasing skin and core body temperatures. The heat the body would normally throw off is then trapped underneath the blanket. You wake up feeling too hot to sleep.

Here are two ways to keep from overheating at night:

  • Use sheets and blankets made of a breathable fabric such as cotton. Fabrics like polyester are more likely to trap heat rather than allow for its release.
  • When you cover up, see if keeping your feet outside the covers helps. You lose lots of heat through your extremities, so keeping them uncovered, or partially covered, may make you comfortable enough to sleep through the night.

Help for Sleep Onset Insomnia

It’s easier to go to sleep when core body temperature is falling, and people who have problems falling asleep—sleep onset insomnia—may have trouble cooling down at night.

Ideally, the temperature in the bedroom should be a little lower than is comfortable during the day. But there are also ways to facilitate internal heat loss. Activities that increase skin temperature eventually help to cool you down. Warming the skin dilates blood vessels close to the skin. This enables the release of body heat and a lowering of core body temperature to occur for a few hours after the activity ends, in turn facilitating sleep.

Early in the evening these activities may trigger processes that help you fall asleep:

  • Take a hot shower or bath
  • Spend time in a sauna
  • Do a resistance workout or aerobic exercise

As you’re winding down on cooler nights, mild heating of the hands and feet may dilate the blood vessels enough to facilitate heat loss, lowering your core body temperature and inducing sleep. But this is a losing strategy on the warmer nights. Lightly clad and barefoot is the way you want to be.

If you’re sensitive to temperature changes at night, what have you found that helps?

Insomniacs, Let There Be Light

If you’re prone to insomnia when it’s chilly outside, the problem may have to do with too little exposure to daylight in the colder months of the year. Working in well-lit conditions and using a light box may help to relieve your insomnia symptoms.

Use a light box early in the morning or in the evening, depending on your insomnia symptomsEvery November I hear increasing numbers of complaints about insomnia. Some people say they feel sleepier in the evening, go to bed early, and wake up at 3 a.m., unable to get back to sleep. Others toss and turn for hours before falling asleep only to oversleep their alarm clocks.

If you’re prone to insomnia when it’s chilly outside, the problem may have to do with too little exposure to daylight in the colder months of the year. Working in well-lit conditions and using a light box may help to relieve your insomnia symptoms.

A new meta-analysis suggests that bright light may be an effective form of therapy for insomnia all year round. But the effectiveness will depend on several things, including the timing of the light exposure and the intensity of the light. Here’s more about it.

A Gold Standard for Night Owls and Early Birds

The use of bright light therapy to treat circadian rhythm disorders—situations involving a mismatch between a person’s preferred sleep time and the alternation of daylight and darkness—is now standard practice. Results of the meta-analysis back these practices up:

  • Night owls tend to fall asleep and wake up quite late, missing morning activities. Their body clocks run slow, completing a daily cycle every 25 to 26 hours. Treatment calls for use of a light box immediately on waking up. Early exposure to bright light shifts their sleep cycle to an earlier hour and helps synchronize their circadian rhythms to the 24-hour day.
  • Early birds are usually struggling to keep their eyes open after 8 p.m. Their body clocks run fast, completing a cycle every 23 to 23.5 hours. The usual advice to early birds is to use the light box in the evening to postpone sleep and tune their internal rhythms to the 24-hour day.

Circadian Rhythm Factors in Insomnia

Surprisingly, the meta-analysis offers even more support for the idea that bright light therapy can improve the sleep of insomniacs. This may be due in part to the design of the studies reviewed. But it also suggests there may be a circadian component in insomnia, an idea that has been around a while. “Circadian rhythm factors may be involved in insomnia in several ways,” sleep investigators Leon Lack and Richard Bootzin have written in textbook on treating sleep disorders.*

People with sleep onset insomnia—trouble falling asleep at the beginning of the night—may have a mild version of the night owl problem. Our body clocks may run a little bit slow, completing a cycle once every 24.5 hours (rather than every 24 or every 24.2 hours, which in humans is the estimated norm). In certain situations—reduced exposure to light; sleeping in on weekends; working evening shifts—our internal sleep–wake rhythm may move farther and farther away from the daily alteration of daylight and darkness, exacerbating our trouble falling asleep.

Likewise, older adults who are increasingly prone to nod off after dinner may wake up feeling wired at their usual bedtime and have a tough time returning to sleep. Or if they do succeed in sleeping through the night, like early birds, they may not be able to sleep past 3 in the morning.

Light Exposure: Time It Right

Light can have a phase-shifting effect on the circadian system and blocks secretion of melatonin, a hormone associated with the night. So bright light may be used to shift sleep to a slightly earlier hour (which may help sleep onset insomniacs) or to prolong wakefulness in the evening. But the light exposure has to come at the right time of day.

Sleep onset insomniacs (whose goal is to get to sleep more easily) will—like night owls—want to expose themselves to bright light immediately upon waking up in the morning. The human body is most sensitive to light when it’s least expected. So half an hour’s exposure to bright light emitted from a light box as you’re getting dressed, eating breakfast, and reading the paper will be much more helpful than a longer exposure to light delivered later in the morning.

Older insomnia sufferers prone to drifting off too early in the evening may be able to remain up and alert until later if—while they relax after dinner with a book or in front of the TV—they do so in a room flooded with light (or better yet, seated next to a light box, which emits a lot more light than standard lighting fixtures). Delaying bedtime may also help to consolidate sleep at night and possibly extend sleep a little later in the morning.

Higher Intensity Light for Better Results

Authors of the meta-analysis found that in the insomnia studies they analyzed, the higher the light intensity, the greater was the effect. So if you’re shopping for light boxes, pay attention to the intensity of light different products emit. A light box that delivers light at the intensity of sunlight (10,000 lux) will give you the biggest bang for your buck.

If you’ve used a light box, what effect (if any) has it had on your sleep?

* Leon Lack and Richard Bootzin, “Circadian Rhythm Factors in Insomnia and Their Treatment,” in Treating Sleep Disorders: Principles and Practice of Behavioral Sleep Medicine, ed. Michael Perlis and Kenneth Lichstein (Hoboken: Wiley, 2003), 305-34.

Insomnia or Delayed Sleep Phase Disorder?

Sometimes I hear from people whose sleep problem sounds more like a circadian rhythm disorder than insomnia. Laurel wrote that she’d always been a night owl. So she was taking sleeping pills to get to sleep at night.

But if her problem is due to a delayed or sluggish body clock—if what she has is delayed sleep phase disorder (DSPD)—she’d be better off with other types of treatment. Here’s more:

Night owls are better off with bright light therapy than sleeping pillsSometimes I hear from people whose trouble sleeping sounds more like a circadian rhythm disorder than insomnia. Here’s what Laurel wrote:

 

 

 

 

I have trouble sleeping virtually every night—it is not intermittent—and I always have. I was a poor sleeper as a child, staying up until very late (3 a.m. to 5 a.m.), then being exhausted during the next school day and napping in the afternoon . . . continuing the vicious cycle. This pattern has pretty much stayed the same throughout my adult life. It seems to run in the family, as my mother had awful insomnia, as does my sister.

Laurel was taking sleeping pills to get to sleep at night. But if her problem has mainly to do with her body clock—if what she has is delayed sleep phase disorder (DSPD)—she’d be better off with other types of treatment.

Symptoms of DSPD

DSPD symptoms are similar to the symptoms of people with sleep onset insomnia:

  • Trouble falling asleep at bedtime
  • Catastrophic thinking at night (related to how their inability to fall asleep will affect their performance or interpersonal functioning the next day)
  • Poor cognitive functioning in the daytime and irritable mood

But in one fundamental way, the symptoms associated with the two disorders are different. Sleep onset insomniacs are inclined to poor sleep regardless of sleep opportunity. People with DSPD, in contrast, can generally get a good night’s sleep when allowed to sleep during the hours of their choosing (as, for example, when they’re on vacation). Their sleep problem has mainly to do with timing. School and work obligations fit poorly with their internal circadian rhythms. The result is sleep loss, poor performance, and, over time, reduced life prospects.

How DSPD Develops

It begins in adolescence. Then, for unknown reasons, children experience a biological delay in their sleep pattern. This delay causes them to want to go to bed and get up later (which is why later school start times for middle and high school students makes so much sense).

Then, as people reach the age of 20 or so, most of us start shifting backward again to earlier preferred bed and wake times. But a small number of people don’t shift back. They become night owls, and their preference to stay up till 3 and in bed till 11 can persist into middle age and beyond.

Delayed Circadian Rhythms

What keeps people like Laurel running late? Two phase markers determine when we feel like sleeping and when we’re ready to wake up. Onset of melatonin secretion is one. Melatonin secretion is negligible during the daytime but high at night, starting about 1 to 2 hours before normal bedtime. Research has shown that melatonin secretion begins about 4 hours later in people with DSPD than in normal sleepers.

The second phase marker is core body temperature. We’re physiologically alert at times when our core body temperature is high and sleepy when it’s low. Normal sleepers’ body temperature is highest—and physiological alertness, greatest—in the evening from about 6 to 9 p.m. In people with DSPD, this temperature high occurs 2 to 6 hours later.

The lowest core body temperature in normal sleepers—when people are sleepiest— occurs around 5 a.m. Research has shown that the body temperature low occurs on average over 2 hours later in people with DSPD. No wonder they can sleep right through buzzing alarm clocks.

A Longer Circadian Period

Studies have also shown that people with DSPD have longer-than-normal circadian periods. The average circadian period in humans—the time it takes to complete a full cycle—is 24 hours 12 minutes. Exposure to sunlight corrects for the 12-minute delay and keeps most of us running on 24-hour days.

The body clock in people with DSPD tends to run slow, cycling once every 25 or even 26 hours. The 1- or 2-hour advance needed to bring them into sync with the 24-hour day is harder to accomplish, say sleep experts, and likely another cause of DSPD.

Treatments

The gold standard in treatment for people with DSPD is early morning bright light therapy combined with a melatonin supplement taken around dinnertime:

  • Bright light: The light source can be the sun or a light box that disseminates light at 10,000 lux. Light exposure should occur immediately upon waking up. Two-hour sessions are most effective.
  • Melatonin supplement: Phase advances are also larger when morning bright light therapy is combined with a melatonin supplement taken late in the afternoon or early in the evening. In a recent study, 0.5 mg of melatonin taken late in the afternoon and 30 minutes of bright light therapy in the morning produced 75% of the phase shift that occurred with the 2-hour light exposure.