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While everyone experiences different sleep problems, those who suffer from symptoms such as "waking up two or three hours after falling asleep" or "waking up repeatedly during the night and then being unable to fall back asleep" may be experiencing "middle-of-the-night insomnia."
This article explains the causes of middle-of-the-night insomnia and how to treat it.
What is middle-of-the-night insomnia?
Middle-of-the-night insomnia (chūtō-kakusei) is defined as waking up multiple times after falling asleep and before waking up the next morning. However, it's generally not a problem if you wake up a few times for a few seconds during the night, or if you can fall back asleep quickly within a few minutes after waking up once. This term specifically refers to situations where a person wakes up clearly enough to be aware of it, and then cannot fall back asleep, or falls asleep only to wake up again soon after.
Symptoms of middle-of-the-night insomnia include daytime sleepiness, fatigue, and decreased concentration due to not being able to sleep soundly until morning. Furthermore, if these symptoms persist, they can lead to increased stress and anxiety, so caution is necessary. Middle-of-the-night insomnia is a symptom that significantly impairs sleep quality and has a negative impact on both physical and mental health.
Difference between early morning awakening and middle-of-the-night insomnia
A similar symptom is early morning awakening (sōchō-kakusei).Early morning awakening is defined as waking up more than two hours before the intended wake-up time and then being unable to fall back asleep, or being unable to sleep soundly even if able to fall asleep, and is distinct from middle-of-the-night insomnia.
While both of these symptoms were previously considered more common in the elderly, it is said that since the COVID-19 pandemic, symptoms of early morning awakening have also been observed more frequently in young people aged 20s to 30s. Additionally, it is known that women are more affected than men. One contributing factor, particularly for women in their late 20s to 30s, is often being woken up by children.
If you occasionally wake up, there's no need to worry excessively. However, if you experience daytime discomfort or if middle-of-the-night or early morning awakenings occur three or more times a week for three months or longer, it indicates chronic insomnia.
Causes of middle-of-the-night insomnia
There are multiple causes of middle-of-the-night insomnia, including aging and stress.
- Aging
- Stress
- Side effects of illness or medication
- Irregular lifestyle habits
- Sleep habits
Let's look at each of these causes to see which ones might apply to you.
Aging
Sleep changes associated with aging are one of the main causes of middle-of-the-night insomnia. As people get older, changes in sleep architecture occur, such as a reduction in total sleep time, a decrease in slow-wave sleep (deep non-REM sleep), and a decline in sleep efficiency. Due to these physiological changes, older adults tend to have more difficulty falling asleep and are more prone to middle-of-the-night insomnia, where they wake up repeatedly.
Furthermore, frequent urination is also cited as a cause of middle-of-the-night insomnia. As people age, frequent urination becomes more common due to reduced bladder capacity, dementia, prostate enlargement, etc. If nocturnal urination is severe, it is recommended to consult a medical institution such as a urologist.
Stress
Generally, during sleep, the parasympathetic nervous system, which relaxes the body, becomes dominant. However, stress activates the sympathetic nervous system, disrupting the balance of the autonomic nervous system and lowering sleep quality. Furthermore, excessive secretion of stress hormones like cortisol due to stress also degrades sleep quality, making it easier to wake up in the middle of the night, so caution is needed.
The main causes of stress are listed below:
- Concerns about workplace relationships or job content
- Difficulty adapting to a new work environment
- Unable to relax when returning home after work
- Experiencing environmental changes due to the COVID-19 pandemic or anxiety about the future
- Consuming alcohol, caffeine, or tobacco (nicotine) which promotes alertness before sleep
- Decreased physical activity during the day due to working from home
Initially, the inability to sleep is caused by stress, but gradually, the inability to sleep itself becomes a source of stress. The pressure and anxiety of "I have to sleep!" can lead to shallow sleep, creating a vicious cycle. Therefore, try to relax before bedtime.
Side effects of illness or medication
Causes of middle-of-the-night insomnia include sleep apnea syndrome, periodic limb movement disorder, and depression. Here we explain the different symptoms of each.
Sleep Apnea Syndrome
Sleep apnea syndrome is a condition where breathing repeatedly stops during sleep. Repeated breathing cessation during the night can lead to shallow sleep and waking up in the middle of the night. It primarily occurs due to a narrowed airway, and is generally common in individuals with obesity or a small jaw.
However, symptoms may also appear as the strength supporting the airway weakens with age. If you snore loudly almost every night, you may have sleep apnea syndrome.
Periodic Limb Movement Disorder
Periodic Limb Movement Disorder (PLMD) is a sleep disorder in which involuntary movements, primarily of the legs, involving rapid contraction and relaxation of muscles, occur repeatedly during sleep.
These movements disrupt deep sleep, leading to an increase in middle-of-the-night awakenings. The brain's awakening response caused by these periodic limb movements degrades sleep quality, resulting in frequent awakenings during the night.
Typically, PLMD occurs independently, but it can also co-occur with other sleep disorders such as restless legs syndrome, requiring proper diagnosis and treatment.
High blood pressure
Individuals with high blood pressure tend to experience increased middle-of-the-night awakenings because the sympathetic nervous system becomes dominant, making them prone to tension and excitement.
Depression
Depression patients tend to experience increased arousal during sleep and middle-of-the-night awakenings due to sympathetic nervous system dominance and abnormal neurotransmitter activity. Additionally, the mental stress and anxiety associated with depression are believed to impair sleep quality and trigger middle-of-the-night awakenings.
Furthermore, depression leads to a reduction in slow-wave sleep (non-REM sleep: deep sleep) and makes sleep shallower, increasing reactivity to external stimuli and causing sleep disturbances.
Irregular lifestyle habits
According to the Ministry of Health, Labour and Welfare's health information website, poor sleep quality has been shown to increase the risk of lifestyle-related diseases and exacerbate their symptoms.
Examples of irregular lifestyle habits include:
- Blue light exposure (using PC or smartphone right before bedtime)
- Irregular meals
- Lack of exercise
- Excessive consumption of nicotine or alcohol
- Caffeine before bed
Improving these irregular lifestyle habits will lead to maintaining good sleep quality. In particular, staring at smartphone or computer screens before bedtime stimulates the brain, making it perceive it as daytime, which can cause middle-of-the-night awakenings, so be careful.
Additionally, exposure to sunlight in the morning triggers the brain to secrete melatonin, a hormone related to sleep. However, if your lifestyle rhythm is disrupted, such as working night shifts or staying up late, and you have fewer opportunities to be exposed to sunlight, melatonin will not be secreted, and your sleep quality will decrease. Even young people in their 20s can experience middle-of-the-night awakenings if their activity times are not consistent.
Sleep Environment
Noise and light from outside, such as neon signs, can also cause you to wake up. Even noises as low as those emitted by household appliances like exhaust fans, televisions, or opening and closing doors are said to disrupt sleep for half of people. Therefore, when sleeping, block out noise and light from outside the house and turn off the television and radio.
Furthermore, in hot and humid environments, it becomes difficult to regulate body temperature, making it harder to achieve deep sleep. Therefore, it is important to adjust the temperature and humidity of the bedroom environment, including air conditioner settings, bedding choices, and sleepwear materials.
Bedding that doesn't fit your body type can reduce sleep quality, preventing you from sleeping soundly until morning.
How to prevent middle-of-the-night insomnia
Improving sleep onset and sleeping soundly until morning hinges on identifying the causes and controlling the autonomic nervous system. Here are 6 easy preventive measures.
Reduce stress
Identifying stressors in daily life and finding appropriate coping mechanisms can help improve middle-of-the-night insomnia. For example, taking time to relax or incorporating stress-relief methods like meditation and yoga can be effective in reducing work or relationship stress.
Furthermore, establishing a bedtime routine is crucial for improving sleep quality. Consciously engaging in relaxing activities such as reading or taking a bath can help you go to bed in a calm state, both physically and mentally.
In addition, improving lifestyle habits such as moderate exercise and dietary management can contribute to stress reduction and good sleep. Therefore, aim for a comprehensive approach while being mindful of stress management.
Review your lifestyle habits
To address middle-of-the-night insomnia, it is important to address lifestyle changes in addition to stress management. First, reduce caffeine intake. Caffeine is one of the main factors that lowers sleep quality and causes middle-of-the-night awakenings. It is especially important to be careful before bedtime, and to avoid consuming caffeinated beverages such as coffee and energy drinks.
Additionally, avoid using smartphones before bed and excessive consumption of nicotine and alcohol, as these can disrupt sleep. By maintaining a regular sleep schedule, your body clock will reset, and you will be able to get quality sleep. Fixing your bedtime and wake-up time and maintaining appropriate activity levels during the day can help improve middle-of-the-night awakenings.
Don't force yourself to sleep
If you lie down trying to sleep when you don't feel sleepy, you'll become anxious and your body will tense up.This increases anxiety like "What if I can't sleep again?", which paradoxically makes it harder to sleep. This is not recommended as it can worsen insomnia and make it difficult to feel deeply rested.
Also, the appropriate amount of sleep varies from person to person, so there's no need to force yourself to sleep for longer than necessary.
Take a lukewarm bath
Taking a bath in lukewarm water at around 38 degrees Celsius for 25-30 minutes, about 1-2 hours before going to bed, can activate the parasympathetic nervous system and enhance relaxation. This is recommended for those whose sleep is shallow due to stress.
Additionally, the body temperature that temporarily rises after bathing will drop, inducing sleepiness. For a half-body bath up to the abdomen, bathing in water at about 40 degrees Celsius for about 30 minutes has a similar effect. However, be careful not to take a hot bath over 42 degrees Celsius right before sleep, as this will activate the sympathetic nervous system.
Be particular about your sleep environment and bedding
To improve sleep quality, it is important to properly adjust the temperature and humidity of your bedroom. The acceptable indoor temperature range is 13 to 29 degrees Celsius, and the temperature inside the futon is ideally around 33 degrees Celsius. Additionally, external stimuli such as light and sound can affect sleep quality, so strive to create a dark and quiet bedroom environment. Installing blackout curtains can also be effective.
Furthermore, the choice of bedding, such as pillows and mattresses, significantly impacts sleep quality. You can create a comfortable sleep environment by choosing a mattress with the right firmness for you, a pillow of appropriate height, and bedding made of materials suitable for temperature regulation.
Use relaxation items
Aromas and music are recommended as ways to relax before falling asleep. Aromatherapy can have a refreshing effect on both mind and body. You can massage with your favorite essential oil or diffuse the scent in your room with an aroma diffuser.
In particular, scents such as lavender and chamomile are said to have high relaxing effects. On the other hand, listening to music is also a good method. Listening to slow-tempo songs or natural sounds can help the brain enter a relaxed state.
How to spend your time if you wake up in the middle of the night
If you wake up in the middle of the night, it's important to respond calmly and without rushing. First, take a deep breath to calm your mind.
If you don't feel sleepy, don't force yourself to sleep. Instead, get out of bed and create a relaxing space by reading a book or playing quiet music. Light stretching or meditation can also be effective.
Then, when you feel sleepy again, return to your bedroom and go to sleep in a relaxed state. Responding at your own pace without rushing, in this way, leads to quality sleep.
Additionally, the following describes coping methods for sleepless nights, so please refer to them.
【Doctor Supervised】8 Ways to Fall Asleep Instantly! Practice These Now in Bed on Sleepless Nights
Middle-of-the-night insomnia: Focus not just on quantity but also on quality of sleep
Generally, adults need about 7 hours of sleep. However, the amount of sleep needed for the body to recover varies depending on age, constitution, physical condition, and daytime activity levels. Therefore, there's no need to panic if you can't sleep for a certain amount of time.
Recently, attention has been paid not only to sleep duration but also to sleep quality. While ensuring sufficient sleep time is important, if sleep quality is high, the body and brain can rest efficiently even with less sleep, maintaining a clear mind the next morning. This also leads to improved concentration, a stable mindset with less irritation, and better work performance.
To improve sleep quality, it is important to try methods to cure middle-of-the-night insomnia and pay attention to your sleep environment and bedding. Since sleep accounts for one-third of our lives, why not review your lifestyle habits, pillows, and mattresses to make your sleep more comfortable?
Recommended bedding for waking up refreshed and sleeping comfortably
Brain Sleep develops various bedding products to meet our customers' sleep needs and concerns. Here, we introduce the features and highlights of our recommended items.
