48: CHOICE AMONG TREATMENTS FOR INTERRUPTED SLEEP (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 interrupted sleep that are considered in Step D3 of the map.
What about the person who awakens one or more times a night?
The problem is not that the person awakens. Most people have several mini-awakenings every hour during the night, to roll over, adjust the covers, etc. Many people awaken fully one or more times. If a person awakens, gets up, uses the toilet or drinks some water, returns to bed and falls asleep quickly, it’s usually not a problem.
However, if a person typically has difficulty falling back asleep, and he/she loses sleep time, the problem is just as serious as losing sleep in the start or the end of the night.
Here we will organize the causes for not returning to sleep into four categories, following Section 40. They may operate singly or in combination for a given person.
48a. Choosing an intervention for difficulty returning to asleep
In some ways, the problem is parallel to the problem of falling asleep at bedtime. The person may be anxious and obsessing, along with being at least partly rested from having slept for a while. Some of the same treatments may be helpful.
The first temptation is to try to select treatments based on patient symptoms (obsessing, energized, physiologically restless, or just not sleepy). However, patients are so clever at picking symptoms that this enterprise seems confusing and overwhelming.
Instead, it seems more productive – although less direct – to make an inference about underlying sources and address these. We still can make mistakes, but the odds of being on target seem better.
Following Section 40, the four sources to be considered here are:
- Situation or Environment External disruptions or distractions can occur at any time of night. Bringing them under control can make returning to sleep easier.
- Emotional Pressures If the person can’t go back to sleep because of worries, fears, guilt, or obsessive thinking, that emotion or thinking may need to be addressed directly. Relaxation may be counter-productive, allowing the thinking to continue unimpeded.
- Circadian issues. Does the person either finishing the day too soon or extending it too late? If so, we will suggest techniques to fit the day into a more effective pattern, that supports natural circadian rhythms.
- Physiological Drive. Energy depleted at the end of the day may be partly restored, at least partly, by the middle of the night. If so, the drive may not be supporting sleep at that time. We might need to suggest techniques that allow the person to remain fatigued throughout the night.
48b. Example
See 47c
48c. Making the Selection
The following table offers possible treatment approaches for the various sources of insomnia. Each line of the table links to a brief 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 | any time | |||
| X | Interruption mgmt | 30 | immediate | |||
| X | Passive observation | 41 | immediate | |||
| X | Psychotherapy | 10 | ongoing | |||
| X | Relaxation | 24 | immediate | |||
| X | Check eating habits | 9 | evening | |||
| X | X | Sleep restriction | 29 | all night | ||
| X | X | Limit awake time | 34 | immediate | ||
| X | X | Review drug use | 8 | evening | ||
| X | X | Review alcohol use | 8 | evening |
The following paragraphs expand on the labels in the chart and refer ahead to other sections for more detail. In each case, it is up to the patient and clinician to determine whether and how the issue may apply.
Alter Environment: [Situation] The bed, bedroom, home or neighborhood may be sleep-disruptive in some way – too entertaining, dangerous, or otherwise stimulating. There may also be changes in the environment during the night that are disruptive of a person’s sleep. Evidence comes from examination of the circumstances that prevail. 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.
Passive Observation: [Emotional] When thoughts, expectations and fantasies are major issues, 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.
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 natural fodder for psychodynamic work, and that should be noted. 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.” See Section 10 for more.
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. See Section 24
Reconsider eating habits [Physiological] While digestion or food reactions are less likely to interrupt sleep than to make falling asleep a problem, a person’s diet and weight can have an impact here also. See Section 9.
Sleep restriction [Emotional, Circadian] (Section 29) in which you reduce the total amount of time the person spends in bed, to increase the need for sleep while there. This might reduce the number of awakenings and drive a more rapid return to sleep.
Limit Awake Time in Bed: [Emotional, Circadian, Physiological] The person may be so concerned about not getting enough sleep at night that he/she spends extra time in bed, in hopes that sleep will come. This can reduce fatigue, encourage emotional engagement, and throw the person’s circadian rhythm off. Evidence: The person may actually complain of how long it takes to get back to sleep or how much obsessive thinking he/she engages in before returning to sleep. Or, the second column in the second sleep log could provide the information. Treatment might involve limiting time in bed, and having the person get up to do something tiring or distracting instead, as in Section 34.
Review Alcohol and drug use. [Emotional, Physiological] Many people use some kind of drug to get to sleep at night – prescription anxiety medication, over-the-counter drug, alcohol, marijuana, etc. The effect may wear off in the middle of the night, leading to lighter sleep and a chance of awakening. Often the person will be afraid to take a second dose because of the danger of being groggy the next day. Treatment for interrupted sleep needs to consider that the real issue may be finding a better way to fall asleep at night. See Section 8 for more.
48d. Links
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Section 46 Choice Among Treatments for Falling Asleep
Section 47 Choice Among Treatments for Early Awakening
Section 17 Step E