Waking in the night and not getting back to sleep

Waking is normal, remembering it is the difference

Sleep runs in cycles, and between the cycles there are very brief arousals. Normal sleepers pass through them without remembering anything, because they return to sleep within seconds.

In someone with insomnia, a brief arousal like that triggers full wakefulness: realising you are awake, checking the clock, counting how many hours are left, worrying about how tomorrow will go. That chain raises arousal and turns a normal transition into an hour lying awake.

Why you must absolutely not check the clock

It sounds like a detail, but this is one of the most effective pieces of advice there is. Checking the clock does two things at once: it gives the brain a number to worry about, and it starts the calculation of how many hours remain. Both make getting back to sleep harder.

How to do it: turn the clock face away, put the phone out of reach. Set an alarm if you need one, just make the time unreadable during the night.

Physical causes to rule out

What to do once you have woken

1. Do not look at the time.
2. If you notice yourself going round in circles, leave the bed after about 20 minutes. Another room, dim light, something undemanding.
3. Return to bed when you are sleepy, not when you judge that enough time has passed.
4. The next morning, keep the same wake time. Do not lie in to make up for it.

A two-week alcohol test

If you drink in the evening, this is the test worth running before anything else, because it is cheap, quick and gives a clear answer. Drop evening alcohol entirely for two weeks and keep a sleep diary.

The mechanism: alcohol depresses the nervous system, so it shortens the time to fall asleep, which is why many people believe it helps. But once the body has metabolised it, usually after three to four hours, the nervous system rebounds towards higher arousal. The result is a fragmented second half of the night, reduced REM sleep, and waking up unrested despite enough hours in bed.

When waking comes with physical symptoms

• Waking with a sense of choking or gasping. Think sleep apnoea. It needs measuring.
• Waking with a racing heart. It may be a nocturnal panic attack, and it may be a cardiac arrhythmia or low blood sugar. It needs assessing.
• Waking with chest burning or a sour taste. Gastro-oesophageal reflux.
• Waking drenched in sweat. In perimenopausal women this is usually vasomotor; in others, infection and some other conditions have to be ruled out.
• Waking in pain. Addressing the pain is a condition for addressing the sleep, not something to do afterwards.