47: CHOICE AMONG TREATMENTS FOR EARLY WAKING (Revised 3-19-2019)
This section follows Section 11, having to do with sleep timing issues. It helps select from techniques used to deal with early awakening that are considered in Step D2 of the map.
This category is for people who awaken earlier than they intend to or want to. They may also have trouble at other times of the night, so those possibilities should be considered.
This can be a maddening issue: the person wants to get up at 7:00 in the morning but instead awakens at 4:00 and can’t return to sleep. None of the available options seem acceptable – getting up, trying to go back to sleep, or just lying around.
A person may remain frustrated and exhausted all day, possibly resorting to one or more naps, to “catch up”. Naps may help temporarily, but they also can perpetuate the problem, providing just enough rest so that the person is once again wide awake the next morning at 4:00.
There are several suggestions to be made for this issue, but the first thing to check is the actual amount of sleep that the person gets every 24-hour period.
- Waking at 4AM may not be a sleep problem, if the person falls asleep at 8PM every day. The person may only need eight hours a night. The problem is a circadian one, and the answer could either involve going to bed later or finding ways to enjoy being up at 4AM.
- People who take long naps may need less sleep at night, primarily because their physiological drive is partly satisfied.
- People who fall asleep in front of the TV for a couple of hours in the evening may need less sleep at night. Their TV snooze is a nap, affecting both their circadian timing and their physiological need for sleep.
For this, a sleep chart can be helpful. It needs to be more specific than the chart of Section 1.
47b. Sources of Insomnia
The following are ordered around issues that may be giving the person trouble.
Begin by deciding on one or more likely sources of the person’s insomnia The four likely sources to be considered here are:
- Situation or Environment External disruptions or distractions can occur at any time of night. If they wake a person too early, return to sleep may be difficult, and the person’s day starts earlier than he or she might want it to.
- Emotional Pressures If the person is preoccupied with emotional issues – worries, fears, guilt, or obsessive thinking, that emotion or thinking may both make waking more likely and return to sleep more difficult.
- Circadian issues. A person may awaken early if his or her circadian cycle is moved earlier in the day. This would be consistent with an urge to go to sleep early. If so, we will suggest techniques to fit the day into a more effective pattern, that supports natural circadian rhythms.
- Physiological Drive. A person may not be so exhausted at the end of the day that the entire night is needed to restore his or her physiological stores, and the pressure to continue sleeping throughout the night may be easily overcome. This might especially be a problem for people who are bedridden or otherwise physically and intellectually less active than most others. The physiological sleep drive may not accumulate at the same rate as normal, and it can more easily be satisfied. They awaken early because sleep has accomplished its physiological task
47c. Example
Howard has a responsible job, which consumes most of his day. He lives alone and doesn’t have much evening activity. Usually he watches TV for a couple of hours after dinner and goes to sleep about 9. He sets his alarm for 7:00 but he is up at 4 AM, not knowing what to do with himself. So he stays in bed, obsessing about the upcoming day and wondering what is the matter with him. When he does get up, he is groggy and reluctant to leave the apartment and go back to work.
Where can we start? By clarifying the situation.
- If he is really asleep by 9 PM and up at 4, it may be that he is getting enough sleep. This may be a circadian problem.
- We could ask what he does at 4 AM besides obsess. He could have anxiety that isn’t enough to prevent falling asleep but becomes more prominent once his physiological exhaustion is relieved. We could ask him to recount some dreams to look for anxiety, or ask more about work.
- We could wonder what wakes him. Perhaps it is a situational issue that he hasn’t articulated – a change in the light, sound or temperature in his bedroom. Maybe he needs to watch for his awareness when he first awakens.
- We could ask what puts him to sleep at 9:00. Maybe his depression hits after dinner and/or he has something to drink that makes him groggy.
- …and so on.
47d. Making the Selection
The following table offers possible treatment approaches for the various sources of insomnia. Each line of the table links to an expanded description of the treatment in the paragraphs that follow, and those descriptions link to sections of text that present them more completely.
| Source | Treatment | Sect | Tmt timing | |||
| Sit’n | Emot | Circ | Physiol | |||
| X | Alter environment | 5 | in bed | |||
| X | Interruption mgmt | 30 | immediate | |||
| X | Psychotherapy | 10 | when available | |||
| X | Find ways to unwind | 21 | in bed | |||
| X | Passive Observation | 41 | in bed | |||
| X | Adjust schedule | 25 | all day | |||
| X | Light management | 27 | night, morning | |||
| X | Limit bedroom use | 20 | all day | |||
| X | Sleep phase issues | 28 | all day | |||
| X | Regular exercise | 23 | daytime | |||
| X | Relaxation | 24 | in bed | |||
| X | X | Sleep medication | 36 | bedtime | ||
| X | X | Yoga | 39 | daytime | ||
| X | X | sleep restriction | 29 | bedtime | ||
| X | X | avoid naps | 32 | daytime |
The following paragraphs expand on the labels in the chart and refer ahead to other sections for more detail.
Alter the Environment: [Situational] The bed, bedroom, house or apartment, or neighborhood may be sleep-disruptive in some way. There may also be changes in the environment during the night that lead to earlier awakening. Evidence comes from examination of the circumstances that prevail when the person awakens. Treatment involves modifying the environment to eliminate or reduce the disruption. This was discussed in Section 5, but it may bear re-examination.
Interruption Management [Situational] (Section 30) Practical suggestions to just handle the situation – temperature, hunger, thirst, need to urinate, interesting ideas and dreams.
Psychotherapy. [Emotional] This link may not be necessary, because the assumption here is that the examination of a person’s insomnia occurs in the context of ongoing psychotherapy. However, dreams, fantasies and obsessive thoughts are fodder for psychodynamic work, and that should be noted. See Section 10 for more. You can have the person keep track of themes that keep coming up, thoughts that interfere with calmness, and explore them in therapy. Often they will appear in dreams. It can be helpful for the person to keep a pad and pencil next to the bed, and sit up and record the thought or dream. This can also be a technique for dismissing it temporarily: “Now I won’t forget, and I can deal with it tomorrow.”
Find ways to unwind. [Emotional] Section 21 lists a few other suggestions for shutting down a mind that just keeps going on with a succession of thoughts and ideas.
Passive Observation: [Emotional] When thoughts, expectations and fantasies are major sleep disruptions, a person can simply observe them come up and keep track of them, without participating in trying to find solutions. Over time, they may simply fade and sleep will be possible. See Section 41.
Adjust Schedule: [Circadian]The person goes to bed at widely different times on different days, or gets up at widely different times, so his/her body is confused about when to sleep. Evidence might come anecdotally from the patient; or from the “Time to Bed” column of the second sleep log. Section 25 addresses this issue.
Light Management: [Circadian] The person’s day may begin with bright light exposure before the time to awaken. Evidence for this issue might come from asking what awakens him or her. Treatment may involve changing the environment or wearing a sleep mask. See Section 27.
Limit Use of Bed and bedroom: [Circadian] The bed may be used for a variety of activities other than sex and sleep. Some people read in bed, watch television, study, go over sales receipts, talk on the telephone, eat and drink, and so on. The bed has lost its unique function. Evidence might come from the patient’s answers to questions about what is happening in bed, either anecdotally or in reaction to the “Amount of Time to Get to Sleep” column in the second sleep log. Treatment involves limiting bedroom functions. This problem is addressed in Section 20.
Sleep Phase Issues: [Circadian] Here we consider people whose circadian cycles begin and end at different times from other people and the rest of their world. This can be a particular problem for elderly people, who tend to go to bed earlier and awaken earlier than others. The question is how to get them in better synch with others or the world. It might be a milder form of sleep phase disorder. See Section 28.
Regular Exercise [Physiological] It may be that the person simply isn’t getting enough exercise to be energized during the day and to be sleepy all night. Evidence: To track this, you might need to revise the sleep log to include a record of exercise and other physical activity in a day-by-day record. This is discussed in Section 23.
Relaxation Techniques: [Physiological] Here the general notion is for the he person to be able to create moments of physical and psychological calm, and to be able to use them to get back to sleep if they awaken too early. Returning to a dream can sometimes aid the process. See Section 24
Sleep medications [Emotional, Circadian, Physiological] have a mixed utility, typically being recommended for short-term relief of serious difficulties falling asleep but is usually not a good idea for long-term treatment of the problem. Medications with a long half-life can make a person sleep later but may leave them groggy the next day. Some anxiety medications can help a person get to sleep at bedtime but have short half-lives that wear off. If the person’s anxiety returns during the night, it may contribute to early rising. Treatment may involve replacing the medications the person currently uses to fall asleep with non-medical alternatives. (See Section 36.)
Yoga [Emotional, Circadian] can be used in in the service of better sleep, as a way of working on relaxation and body toning. More on this is in Section 39.
Sleep Restriction [Emotional, Circadian] is a formal approach that combines several components. (a) the person gets up at a consistent time, no matter how sleepy; and (b) avoids naps, and (c) goes to bed late enough to fall asleep quickly. Based on the idea that some people have circadian cycles that are longer than 24 hours, it forces a person to adjust a 24-hour cycle. (See Section 29.)
Naps: [Circadian, Physiological] A person may be taking naps during the day, thus reducing the need for sleep at night. This could especially be true if the naps are long or late in the day. Evidence for this could simply be the person’s admission that he/she takes them, or it could appear in the sleep log, by adding up the total sleep time (nighttime plus naps). It could also be that days with naps are followed by nights with less sleep. To work on this issue, go to Section 32.
47e. Links
- Menu
- Section 46 Choice Among Treatments for Falling Asleep
- Section 47 Choice Among Treatments for Early Awakening
- Section 48 : Choice of Treatments for Interrupted Sleep
- Section 17 Step E